Tuesday, 17 March 2009

The Tip of the Iceberg

See this shocking, but unsurprising (if you get what I mean) story from the Independent today:

Tuesday, 17 March 2009

Appalling standards of care at a hospital trust put patients at risk
and led to some dying, according to a damning report out today.

The "shocking" state of affairs at Mid Staffordshire NHS Foundation Trust
meant patients admitted as emergencies suffered due to serious lapses in care.
Between 400 and 1,200 more people died than would have been expected in a
three-year period, the head of the investigation for the Healthcare Commission
Families have described "Third World" conditions at the trust, with
some patients drinking water from vases because they were so thirsty and others
screaming in pain.
The Commission launched an inquiry after concerns were raised about higher than normal death rates in emergency care, in particular at Stafford Hospital.
The trust argued the anomalies were due to "problems with
its recording of data and not problems with the quality of care for patients",
the report said.
Not satisfied with this reponse, the Commission launched a
formal investigation last year, sifting through more than 1,000 documents and
interviewing some 300 people. It found deficiencies at "virtually every stage", including inadequately trained staff who were too few in number, junior doctors left alone in charge at night and dirty wards and bathrooms.
Some patients were left in pain or needing the toilet, sat in soiled bedding for
several hours at a time and were not given their regular medication, the
investigation found. Receptionists with no medical training were also left
to assess patients coming in to A&E. The investigation found heart
monitors were turned off on wards because nurses did not know how to use them
and some patients were left dehydrated because nurses did not know how to work
intravenous fluid systems properly.
The report also found that the Government's target for patients to be seen within four hours at A&E meant patients could be taken to "dumping grounds" to avoid breaching the target. Some patients had their operations cancelled for up to four days running and were "nil by mouth" for most of those days, leaving them hungry and thirsty. In one ward, 55% of patients were found to have pressure sores when only 10% had sores on arrival. The trust was also found to be 120 nurses short in
2007/08, of which about 17 were needed in A&E, 30 in surgery and 77 on
medical wards.
The Commission said the trust's board was more focused on finance, targets and achieving foundation trust status, as well as its desire to save £10 million.
Despite the fact concerns had been raised about the trust,
it was awarded foundation trust status - designed to mark out outstanding
hospitals - just weeks before the investigation was launched.
Earlier this month the trust's chief executive, Martin Yeates, stepped down and has now been formally suspended on full pay, while chairman, Toni Brisby, resigned.
Sir Bruce Keogh, medical director of the NHS, said today there had been a "gross and terrible breach of trust" of patients, adding the report showed there had been a
"complete failure of leadership". He added: "I'm proud of the NHS but actually I'm really saddened by this report."
Dr Heather Wood, who led the Commission's investigation, said the number of excess deaths between April 2005 and March 2008 was between 400 and 1,200, although it was expected the figure of 400 would be closer to the mark.
It is not clear how many of these deaths could have been avoided.
Chairman Sir Ian Kennedy said the report detailed "a shocking story".
"Our report tells a story of appalling standards of care and chaotic systems for looking after patients," he said. "These are words I have not previously used in any report. There were inadequacies in almost every stage of caring for patients. "There was no doubt that patients will have suffered and some of them will have died as a result."
Local MP, David Kidney, said: "The exhaustive Healthcare Commission report is both definitive and damning. "In A&E, emergency admissions and medical wards 10, 11 and 12, care standards were unacceptable during the three-year period ivestigated. As a result, some patients experienced intolerable conditions and lessons
were not learned by the hospital trust from those experiences. So more
patients suffered. It is galling for patients and patients' relatives and
carers that their complaints were not believed or were fobbed off with excuses
and promises that the report shows were worthless."
Julie Bailey, 47, has spent 14 months campaigning for an inquiry into Stafford Hospital following the death of her mother in November 2007.
Ms Bailey, from Stafford, was so concerned about the care being given to her 86-year-old mother Bella that she and her relatives slept in a chair at her hospital bedside for eight weeks.
"What we saw in those eight weeks will haunt us for the rest of our lives,"
she said.
"We saw patients drinking out of flower vases they were so thirsty. There were patients wandering around the hospital and patients fighting. It was continuous through the night. Patients were screaming out in pain because you just could not get pain relief. Patients would fall out of bed and we would have to go hunting for staff. There was such a lack of staff. It was like a Third-World country hospital. It was an absolute disgrace."
Eric Morton, chief executive of the trust, apologised to patients
but said "significant changes" had been made within a very short period of time,
including new management, more staff and new systems in A&E.
Health Secretary Alan Johnson also apologised to families and patients, and announced a review of current A&E services at the hospital as well as one to establish how long problems had been going on for.
He said: "There was a complete failure of management to address serious problems and monitor performance. This led to a totally unacceptable failure to treat emergency patients safely and with dignity."
Shadow health secretary, Andrew Lansley, said: "The public will be rightly shocked by the poor standards of care exposed at this hospital. It is unacceptable that the pursuit of targets - not the safety of patients - was repeatedly prioritised, alongside endless managerial change and a 'closed' culture, which failed to admit and deal with things going wrong."

You have to hope - and I do believe it's so - that this hospital is an extreme case. That said, where else was this incessant drive towards targets and efficiency savings going to lead? It's a bit disingenuous for the Government to feign mock horror. Who was it that was driving the "modernisation" agenda in the first place? It was New Labour who introduced the concept of Foundation Hospitals, these flagship hospitals that would run on an enterprise ethos and would put the supposedly fuddy-duddy, crumbly old traditional NHS to shame.

It's high time we took stock of what really matters and gave all the gurus who lied to us the heave-ho.

In Scotland, healthcare is devolved to the Scottish Parliament, thankfully. We may have been spared the worst excesses of capitalist meddling, but there are no grounds for complacency.

I remember the early 90s, working as a newly qualified ward nurse when the Tories introduced their wave of health service modernisation. They introduced the purchaser/provider split and did a whole load of nonsense meddling and right-wing muscle flexing. It was all based on dogma, not evidence. My line manager took me to one meeting where I heard the senior management case for the purchaser/provider split, which was being implemented without meaningful discussion. I asked what happens if the purchaser has paid for 900 hip replacements and I am the 930th person who needs one? I was callously told: "you go somewhere else." So patients were to be carted around like tins of beans to be stocked on empty shelves, without a thought for the inconvenience to stressed-out visiting relatives.

I witnessed one nonsense decision which was taken on the basis that the high dependency unit was "under-utilised." [In practice it is actually essential that this sort of unit has spare capacity to accommodate emergency admisssions and thorough cleaning of bed areas between admissions.] Our right-wing, new breed of managers decided waiting list patients were to be housed in the spare capacity in the high dependency unit and left it to the "clinical director" - a busy clinician - to implement the decision. Of course it failed after one afternoon. Waiting list patients who were hospitalised for a hernia repair or treatment of their haemorrhoids were absolutely freaked out by close proximity to so many seriously unwell, highly dependant patients. They also had no access to proper washing facilities or a TV room or a dining area, as high dependency patients don't require these services. I did a little management study (not a popular one with the movers and shakers in either hospital management or higher education) on this particular decision. I counted that there were 19 paid managers involved in taking the decision, but only the clinical director - a clinician who was a busy expert surgeon - was actually responsible for implementing it. He had received half a day of management training.

You could almost laugh at those examples, but it got decidedly unfunny when I had to cancel patients' surgery on the day it was due, due to arbitrary decisions to close four or six or eight beds, with immediate effect. When it got to the third time that I told a man with cancer his surgery had been cancelled, I was handing him the complaint card and advising him on how to complete it. He wouldn't though, despite travelling a fair distance, so always actually being at the ward before finding out his surgery was cancelled. He had too much respect for the idea of the NHS and didn't want to cause the staff any trouble. His first wife had died of cancer. The first husband of his current wife had also died of cancer. But this couple quietly suffered their fears of cancer that spreads while waiting for surgery, rather than cause a fuss. And all this at the time of the much vaunted "Patients' Charter" which allegedly improved patients' rights. Sometimes I wanted to spit on that document.

So you can imagine my relief, in 1995, when I met my local Labour MP in the pub, and he asked me: "How are things in the NHS?"

But I barely got a chance to draw breath and tell him about cancer patients having their surgery cancelled, far less let him know how staff were using every aspect of themselves to paper over the cracks appearing in the NHS, by arriving early, working late, buying things for patients, never taking breaks..........

He launched into effusive mockery of how old fashioned I was, and informed me that New Labour weren't going to change health policy that much, that like the Tories they also believed the NHS needed a healthy dose of "modernisation." I fumed all night, but could barely get a word in, as, typical of New Labour, he is the sort of guy who is totally impressed by the sound of his own visionary voice. Eventually he noticed and remarked that I was a bit quiet. I told him I was deeply un-impressed by New Labour. He said: "Never mind, just keep the money rolling in." He actually rubbed his hands when he said that! It had obviously escaped his notice that I had already cancelled my Labour Party membership and subscription. Thankfully the money has finally stopped rolling in, as witnessed by the tricks New Labour have had to resort to in recent years, in order to fund their election campaigns.

New Labour's spell in charge of the NHS has been heart-breaking. I worked in intensive care at a PFI hospital. Support services were privatised, so detergent was rationed, the cleaner had to use a dirty mop-head to clean the floor, nutrient-lite microwave meals were transported from Wales and money was extorted from families who phoned ill relatives, or paid for access to TV for them. The thing that sickened me the most, though, was that we had to lay bets on the expected date of death of deteriorating critically ill patients. This was because the families were only entitled to one day's free car-parking - on every other day they had to pay £10. So if we guessed wrongly, they ended up being handed a £10 parking fee along with the death certificate and their loved one's belongings.

There was a lot more that scunnered me, like the patronising supposed "consultation" meetings on acute service cuts [strange how they never let me speak], or having to face elderly sick relatives who had braved four-hour journeys to distant hospitals where services had been rationalised to. I stomached a lot that made me heart sick.

I finally left the acute sector over a document entitled "Critical Care Without Walls." (http://www.sehd.scot.nhs.uk/publications/report.PDF) (http://tinyurl.com/dy8u4z). On the face of it, it sounded like a good idea. Patients should be able to get critical care when they need it, no matter where they are in the hospital. But how is it possible to do this without having the levels of staffing and equipment that are available in critical care? I attended a conference a few years before this document was released and was told by a Government health economist that they were "coming after our critical care staffing levels." And that's what "Critical Care Without Walls" is really about. It wasn't long before us ITU nurses were being farmed out all over the hospital as pairs of hands and we lost the polish of our specialist skills. Things that we could previously do automatically we now had to think hard about, losing vital minutes while a patient was deteriorating. When you think about it, if that document was ever truly about providing "critical care without walls," the Government would have ensured that ITU staffing levels were available in every ward, rather than diluting down ITU staffing levels to closer to ward levels and sprinkling a little technical know-how throughout the hospital.

The hospital in Stafford is an extreme case, but it is only the extreme case that proves the rule. All this right-wing dogma has got to be challenged, because everywhere we look it has caused nothing but harm. Up to 1200 unneccessary deaths, at one hospital, over three years! That is staggering, disgusting, criminal!

It's high-time we gave the right-wing yes men and women in the NHS their marching orders. Maybe we could even start rewarding the recalcitrant loony lefties who always spoke out against this sort of thing (joke + smile.)

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