Nursing in the NHS: a scandal of our times
The standard of nursing in many (not all, but many) NHS hospitals is appalling. Almost everyone has experienced, or knows friends and relatives who have experienced, atrocious and negligent treatment by nurses in NHS hospitals, including especially agency nurses. For years open discussion of this calamitous reality has been taboo. We value the NHS, as widespread resentment of recent attacks on it by American right-wing opponents of US healthcare reform has shown. Hardly anyone in Britain wants to abandon the National Health Service’s core principle: medical treatment available to all, regardless of income, free at the point of delivery, whether at the local GP doctors’ practice or in NHS hospitals and clinics. Much NHS treatment and many, probably most, NHS staff are first-class. But far too many nurses are indifferent to their patients’ needs, indolent, arrogant and domineering, sometimes downright cruel. Basic aspects of patient care are often neglected because the more basic forms of treatment are regarded by qualified nurses as beneath them. Beds and whole wards are allowed to remain filthy for days; patients sometimes go unfed and unwashed; appeals for help in emergencies or at times of urgent need go unanswered. Care of the old seems to be especially bad, but the old are by no means the only victims of this scandalous neglect.
One recent example of disgraceful standards of nursing in a famous London NHS teaching hospital is documented in a searing letter of outraged complaint to the relevant hospital trust from a young woman friend, a qualified psychoanalytical psychotherapist and mother, who has kindly allowed me to put the text of her letter on this website: you can read it here. This is an outstandingly conscientious and observant person and I can vouch without a qualm for the truth of every horrifying detail of her narrative. Indeed I know that some of the things she witnessed and experienced in hospital were even more horrendous than those described in her letter.
There is ample evidence that this is by no means an isolated case. A recent report on nursing care by the Patients’ Association (PA) has aroused huge concern and received massive support from around the country:
The Patients Association has been overwhelmed by the huge number of responses we’ve had to the heart-rending accounts of inadequate patient care that we’ve published today. We’ve been inundated by hundreds of emails and calls from patients across the country contacting us to offer their support and relate their own experiences of poor care. … Newspapers, radio stations and television channels are telling us that they are being flooded with supportive comments from members of the public.
It is very clear, that whilst still representing a small proportion of the care being given by the NHS the numbers of people receiving substandard care are not small. … We feel the immense response we have had from the public is the best answer to continual rebuttals by NHS leaders and the Department of Health as they insist on ignoring the scale of the problem.
We do not wish to attack the nursing profession as a whole and we know the vast majority of nurses do an excellent job but this doesn’t mean incidences of appalling treatment can be ignored or treated as one-offs. Those nurses lacking the caring attitude vital to their role should not be allowed to undermine the work of the rest. We are pleased to see nursing leaders acknowledge this today.
The PA press release accompanying publication of the report demonstrated the largely unacknowledged scale of the problem:
The Patients Association has campaigned for many years to improve the quality of care provided by the NHS and throughout that time our efforts have been fuelled by the accounts we receive from patients and their relatives through our HelpLine on a daily basis. As a consistent pattern of shocking standards of care has emerged we have decided to publish a number of these accounts to highlight the unacceptable experiences facing patients up and down the country on a regular basis. The Patients Association calls on Government and the Care Quality Commission to conduct an urgent review of the standards of basic care being received by patients in hospital and demands stricter supervision and regulation of hospital care. …
Director of the Patients Association Katherine Murphy said: “….Very often these [accounts concern] the most vulnerable elderly and terminally ill patients — it’s a sad indictment of the care they receive.
“These accounts reveal patients being denied basic dignity in their care — often left in soiled bed clothes, being given inadequate food and drink, having repeated falls, suffering from late diagnosis, cancelled operations, bungled referrals and misplaced notes. There are also worrying instances of cruel and callous attitudes from staff towards vulnerable and sometimes terminally ill patients. We hope this report is a wake up call for the Department of Health and the Care Quality Commission — we’ve made a number of recommendations to try and prevent these kinds of things happening to other patients. We hope this report also encourages other people to get in touch with us and tell their stories — we plan to continue publishing accounts until we can be confident that every patient is secured dignity in their care. The people that have come forward for this report are incredibly brave and had one thing in common — they want it stopped.”
Writing in the (London) Sunday Times on 30 August, Minette Marrin, whose column has often addressed the scandal of bad nursing, confirmed the evidence that the problem is not confined to a tiny minority of nurses and nursing assistants in a tiny minority of hospitals:
…there is no shortage of nightmare nurses. I know from many personal visits to hospitals over 20 years, and from many hundreds of heartbreaking readers’ letters over 15 years, that NHS nursing horror stories are legion. Whenever I’ve written an article about them, I get in response a collection of anecdotes that would disgrace a Third World country. And, as the Patients Association report points out, most of these stories are about old people. It is so late in the day for the country to sit up and take notice. Why has everyone been so determinedly deaf to the obvious truth?…
Nurses’ personal standards would have horrified Florence Nightingale. It struck me forcibly how slovenly many nurses were, with loose hair trailing and hanging over patients’ wounds, with unkempt nails and hands all too rarely washed between patients. Many were just mean: they ignored and patronised the patients.
“They bring them to the operating table unwashed, leave them frightened and unfed, distressed by loud music, overflowing catheter bags and bed sores, by dirty sheets and filthy lavatories with blood in the sinks and excrement on the floor,” I wrote. “These are horrors caused not by shortage of money, but by personal laziness, indifference, lack of self-discipline or of any discipline at all.” And so on. There was total silence from the Royal College of Nursing and the General Nursing Council. Yet not only patients but also many nurses and doctors wrote to me in agreement, describing even worse things. So why didn’t nurses and doctors protest?
Minette Marrin makes an important point here about the failure of hospital doctors to take effective action to stamp out disgracefully sub-standard nursing. Part of the problem, perhaps indeed at the root of it, is that most doctors spend far too little time in hospital wards, talking to patients and nurses, just watching and listening. Of course they are busy and often over-worked, but this is an absolutely essential part of the jobs for which consultants in particular are handsomely paid. Some consultants and other doctors do it: why can’t others? Often the only time a patient sees the consultant supposedly responsible for his or her care is when the great man (or, occasionally, woman) does the ‘hospital round’, accompanied by a small flock of obsequious and anxious junior doctors, often spending no more than three or four bland minutes with each patient. These royal visits may occur as rarely as once a week. The nurses know when a visitation is due and clean up the patients, the beds and the wards in preparation for it. It’s often said that the Queen must assume that every building in the land smells of fresh paint. Hospital consultants who never visit, unannounced, the wards where their patients lie in squalor no doubt believe similarly that all wards are clean and tidy, in the tender care of attentive and diligent nursing staff, at all times of the day and night. Even junior doctors and registrars commonly appear to be in a great hurry to get away from the wards lest they be waylaid by distressed and neglected patients: they are often more frightened of the nurses than by the likely consequences of the neglect suffered by their patients. Surprise snap visits by hospital managers, especially Chief Executives, also seem as rare as hens’ teeth. Do these great personages have any idea of what’s going on under their noses, or how the staff for whom they are responsible are failing to do their jobs to even minimally acceptable standards, with sickening consequences for the patients to whom they have an overriding duty of care? If so, why do they not do anything about it, individually and collectively?
As the Patients’ Association says, remedial action is now long overdue. “We hope this report is a wake up call for the Department of Health and the Care Quality Commission.” When will the Department and the Commission stir themselves from their long slumber?
Brian
I remember when my sister trained as a nurse — she was in absolute awe of matron, who insisted on complete and utter conformity to every instruction. The wards were spotless, patients were treated with respect, and nurses had pride in their job. Now, I’ve seen at first hand how lax the standards are. Yes, there are some excellent nurses, but too often they are uncaring, lacking initiative, and simply not up to the job. Where’s matron when you need her?
Brian writes: Rob, I and many others entirely agree. But I doubt if it’s feasible now to re-create the old matron system: with the decline of deference for authority in our society (welcome in many ways), my guess is that many young nurses of both genders would simply refuse to accept a matron’s instructions and authority. Another part of the problem is the outsourcing of such functions as cleaning of wards and catering, so that for example even a matron would not be able to give orders that a ward should be cleaned if the cleaning contractors’ contractual obligations didn’t require them to comply. Yet another problem is the delegation of the more menial parts of nursing care to unqualified or only semi-qualified nursing assistants, so that fully qualified nurses (who now have to be graduates) understandably regard washing patients and emptying their bedpans as no part of their duties; yet these intimate activities used to create an important bond between patient and nurse. And finally one has to recognise the difficulties that often arise from the cultural and even linguistic barriers between a UK-born patient and a nurse who has been recruited from overseas, as a huge proportion of NHS nurses seem to be. Their services are needed and appreciated but it’s often obviously more difficult for some of them to establish the kind of relationship with their patients that used to be almost universal. And finally there’s an unfortunate consequence of the much greater equality of women and their higher aspirations than in the past: an exceptionally capable, compassionate young woman interested in a career in medicine is now more likely to become a doctor than a nurse, thus depriving the nursing profession of some of the people who would have been its natural leaders and role models a generation ago — again, a negative consequence of an otherwise highly desirable change in our society.
I despair when people hearing or reading distressing stories of bad care in hospitals respond as though this is a new problem and specific to the NHS. It is neither, and without a wider and better informed perspective it is not possible to have an informed debate on how to improve practise. So much has been written over the last two centuries, both fiction and non fiction, about the level of suffering in hospitals (and other care institutions) around the world and in every kind of health care system, that one has to wonder at the persistence of the myth of the all powerful and all caring Matrons managing armies of nurses delivering high standards of care across hundreds of hospitals. There may well have been a relatively small number of special individuals who did achieve wonders just as there is almost certainly some special senior managers achieving wonders right now in some hospitals. However you cannot run a large service on the basis of expecting you will be able to recruit very special people to every key post. You have to manage large organisations with an understanding of the dynamics of institutions and of how to motivate people to work in a way which embodies agreed ideals.
That this very difficult has been clearly known since at least the 1960s, but for the sake of brevity I will refer to two authorities. Firstly Enoch Powell, who, as Minister of Health, became aware of the apalling conditions in which many patients were being kept in mental hospitals and mental subnormality hospitals and he kickstarted the revolution that led to the closure of almost all of them. Unfortunately he did not have the advantage of the work of Erving Goffman, the American sociologist who was just beginning his studies of American hospitals (followed by studies of other kinds of institutions) which were published from the early 1960s onwards. His first book- Asylums should be read by everyone who has a pretension to being educated because he shows very clearly how the dynamics of large organisations operate in a way which the needs of staff and patients ( in the case of hospitals) are subjugated to the smooth running of the institution. His work spawned a large number of studies by him and other sociolgists showing that all institutions, not only hospitals but homes for the elderly, prisons, the armed forces, schools, the civil service etc will left to their own devices become concerned primarily with their own continuation.
To put it into a more modern idiom, the default mode of a hospital is to be uncaring, not only to the patients but also to the lower orders of staff who reflect the way they are treated in the way they use what power they have i.e. in the way they treat patients. This is not a counsel of despair, it is just a key element defining the starting point for making things better. Another key element is to get things into perspective. I have’t seen any recent figures but I believe about 80% of NHS patients declare themselves well satisfied with the care they have received. I suspect the figures for the patients of the private sector are not very different and I would be surprised if equivalent figures for all users of the health care in the USA showed similar satisfaction.
However 20% of NHS patients is a very high figure and of course we want it reduced, but providing support to those people who want to destroy the NHS by saying bad care is a problem of the NHS is both factually and ethically wrong.
This is not the place to write a management manual but the basic principles will consist of :-
1) supporting those who are getting it right
2) identifying those who aren’t
3) making it clear to those identified in 2 what is expected of them, and giving them the opportunity to change.
4)You deal approppiately with those who fail to change.
The great bulk of management time and effort should be going into 1 -3 above. Armchair managers sounding off about naming and shaming, or other forms of pilloring people, or sacking are at best just indulging their own uncaring tendencies and at worst they increase the pressures on staff to act to protect themselves which is usually less caring to patients.
Brian writes: Colin, thanks for this. I think everything you say will be very familiar to all those of us who have worked in or tried to manage large or small organisations; much of it is common sense. Your 4-stage management guide for hospitals is fine, but it seems to me that the first step is to encourage by every possible means a widespread public recognition that there is a major problem here, one that has existed for a very long time, and to which no-one with the authority to tackle it seems to be paying attention. The next step is to identify publicly someone with the authority to initiate and enforce reform right across the system. This process clearly needs to begin with ministers. Simply laying down general principles and expecting hospital Chief Executives to apply them will achieve less than nothing. Suggesting that any discussion of the problem constitutes an attack on the National Health Service simply discourages reform and helps to perpetuate a situation which itself damages the NHS far more effectively than discussion of it with a view to remedial action.
I’m not sure to whom you’re referring when you denounce “Armchair managers sounding off about naming and shaming, or other forms of pillor[y]ing people, or sacking are at best just indulging their own uncaring tendencies”: no such remedies were envisaged in this post, which expressly called for action by the Department of Health and the Care Quality Commission, either or both of which must bear the responsibility for a wholly unacceptable situation about which so far nothing effective has been done.
Brian, As I said in my comment of 6 September in your earlier version of this (an-experience-of-nhs-nursing), my 20 years’ experience as a Health Authority member leads me to believe that, if Labour hadn’t scrapped such bodies, along with the inexpensive watchdog Community Health Councils, this kind of appalling situation would be highly unlikely to arise. Individual members of the HAs and CHCs were allocated specific specialties to monitor and they conducted regular and often unannounced ward visits. If the HA members ever failed to spot anything untoward, one could be certain that the CHC members would do so and would publicly pillory the HA in the local press for their blinkered vision. It is not good enough that hospital trusts should be nowadays the last line of monitoring.
Best
CLIVE
Brian writes: Thank you, Clive. The abolition of monitoring bodies such as these does seem inexplicable and obviously mistaken. I can only suppose that it took place in one of Whitehall’s periodic fits of cheese-paring economies, probably in response to some casual tabloid campaign against “government waste” on a slow news day. As a new age of cheese-paring austerity approaches, thanks to the reckless greed of the bankers and the unsustainable borrowing forced on the government to bail them and the economy out, the chances of setting up any new institutional monitoring of nursing standards in NHS hospitals look extremely remote.
My wife is currently in a single sex ward of 5 at the local NHS hospital. It is not too bad, but I am struck by the way the whole place seems to shut down over the weekend. Fortunately my wife felt very seriously unwell on a Thursday afternoon, went to see our GP, who very alarmed by her symptoms, arranged for her to be taken by ambulance to the Medical Assessment Unit onf the local hospital. She remained in the mixed sex MAU overnight. It was not very clean. On transfer to a normal ward the next day, conditions improved but I wondered what would have happened if she had started to feel ill at the weekend with the GP surgery closed down and few professional staff in evidence at the hospital. Our local NHS hospital is relatively new and cost millions to build. It is being constantly enlarged, altered and improved. It is plain that lack of funds for development or pretty huge salaries for senior medical staff and “executives” of one sort or other is not a problem. Nor, it seems, is shortage of well-intentioned staff: there seemed to be plenty of nurses (people in blue uniforms) chatting to each other in the reception areas, and they are nearly always pleasant individuals. I think, if I may hazard a guess, that the problem is managing a huge organisation in which there is very little sense of discipline. No-one can be ticked off for not doing menial tasks, which almost everyone feels are somehow demeaning. Our nurses tend to respond to requests for help if asked politely. Some of the August intake of young doctors although not very good at injections were delightful. This lack of grass roots organisation and commitment seems to me to be a specifically British problem, rapidly affecting immigrant workers until they are no more willing to work in a disciplined fashion than the native British.
I have recently had a hip replacement in a private hospital. It was a much more pleasant experience than if the same surgeon and anesthetist had done the same job in the considerably better equipped NHS hospital. In the private hospital, the staff showed respect for the individual patient, which was a pleasant aspect of the painful business of paying for it out of taxed income.
May I add to the above? I told my wife about the blog and the various criticisms of the NHS. She is still in the local hospital, which is, I discover, a centre of excellence for spinal injuries and cancer and receives extra funding from the NHS as a result of this status. My wife had an MRI scan the other day and her case was reviewed and discussed by consultants with particular expertise in endoscopy procedures (I am not sure of the spelling of this specialisation) in Southampton and Portsmouth all done on their computer screens with the results of the scan also available. They concluded that the tumour to be removed was too big for removal by endoscopic means and that the job would require surgery. The local surgeons will be able to handle this. Surgery these days includes keyhole surgery, which sounds pretty magical to me.
My wife reckons she is getting the best possible treatment. With regard to the nursing staff, my wife thinks they are hard working, very considerate and caring, and possibly more perceptive than we give them credit for. For example, they call patients “my love” or “lovey” but this is generally limited to what the patients call each other. If one is not inclined to use such phrases, the nurses also abstain. We have every reason to be thankful for the existence of this rather splendid service: not perfect, but what is?
Brian writes: Malcolm, many thanks for both of your informative and moving comments. Everyone reading them will be very sorry to read of your wife’s illness and will hope for both of you that the good treatment she is evidently getting will soon restore her to health and happiness. No further response by me is perhaps required, save to accept unreservedly that among the disasters there are still many excellent hospitals and countless excellent, conscientious, efficient and caring nurses. Nearly all of us have nothing but praise for the NHS, and for the principles on which it’s founded. But the sad fact remains that in far too many NHS hospitals, the standard of nursing is appalling — and precious little is being done about it. The case histories cited above are unequivocal evidence for this. Good luck!