Tuesday, 15 February 2011

We don't have to be either workers or a drain

Today there are enough stories about neglect in our care and health services to make you cry. The NHS "fails to treat the elderly with care and respect," says the BBC, adding four reports by witnesses (workers and patients' relatives) telling condemning stories. "Hungry, thirsty, unwashed . . . Elderly people treated by the NHS were denied even the most basic standards of care," says the Independent.

Before that, Johann Hari wrote a moving piece on the neglect his grandmother went through in one care home after another - and, after the overwhelming response the article received, evidently interviewed many people to search for a solution, which he presents here. And although I loathe to link to the Daily Mail, this account by a nurse of the massive culture change her profession has undergone is infinitely worth a read.

The stories she tells are infuriating - heartbreaking for anyone who might have been through this themselves, or knows anyone else who has - and also, although this sounds less impressive but is true all the same, desperation-inducing to someone like me, who has worked in the NHS and whose immediate family still does. Making people better is something that many doctors, nurses and others give their lives to. Someone in my family is (and has been for many years) on call 24 hours a day, three hundred and sixty-five days a year, and is often at work ten or twelve hours a day to make sure the patients get everything they need on top of the mountains of unutterably pointless, illogical and ill-thought-out - and immediately forgotten, to add insult to injury - forms the managers demand he spends hours a day filling in. It's aged him rapidly. And nothing distresses him, or the others, more than learning of mistakes or poor care.

Joan Woodcock, the author who wrote the article in the Daily Mail, does not mince her words about where things have gone wrong:
I am sure that many of the new generation of nurses are as caring as we were. But what chance do they have of showing it when the hospitals in which they work are run not by experienced nurses but by bureaucrats?

Too often these managers fail to realise that patients are people, not commodities, and that management skills acquired in banks and retail ­business don’t necessarily transfer to the running of NHS hospitals.
She adds: "When matrons were phased out at the end of the 1960s and replaced by managers, things soon began to slide. There was no longer any one person in charge of patient care in each hospital, no one with the authority and respect of those like [the strict and demanding matron]."

I've had a couple of good blogs pointed out to me over Twitter. One called BillyNoJob remarks on a conclusion by John Humphrys: "This is not about professional incompetence. It is about inhumanity, lack of compassion, and the most basic failure of respect for other people." Joan Woodcock and Johann Hari's articles amount to the same thing. BillyNoJob adds, unlike them, that he has witnessed many patients treating hospital staff with rudeness and contempt, too. This is especially so when many staff are immigrants, since care is not - as Johann Hari says, too - rewarding or a profession to which Britons are encouraged to aspire.

This shows two problems: firstly that (as Johann Hari also mentions) care is not well-paid, rewarding or a profession to which Britons are in the least encouraged to aspire; secondly the old business of scapegoating. It is a genuine problem when a health worker's English is not very good, not only in medical terms but in euphemisms and non-verbal messages patients are likely to use a lot in terms of their illness and on intimate subjects. This may be a contributing factor; but the atmosphere of distrust and dislike that the tabloids encourage does not get anyone anywhere.

Johann Hari, among others, emphasises the lack of niceness health care workers show - indeed have time to show - to patients who are bored, frustrated, and have nobody to talk to. This lack of time is ruining things for "Militant Nurse", whose outside life and family and doubtless her own health and energy are suffering as she has to work unpaid overtime just to get even the basic jobs done. The ward is horrifyingly understaffed. She is in a state of understandable rage, made all the worse when the patients misinterpret her shortage of time as a lack of caring, and are grateful to the only other worker who is not equipped with the skills of a nurse and as a consequence does have time to make them a cup of tea. Reading her blog, one wonders what keeps any nurse from looking for another job - other than the lack of other jobs available.

Among lack of time and lack of niceness also lies a lack of willingness to take responsibility. Joan Woodcock's article shows how no one person seems to be responsible for any particular task, and various staff are all too keen to say, "That's X's job, not mine" - and therefore it doesn't get done. "Militant Nurse" notes that the consequence of this is that when a problem has to be addressed, whoever happens to be on the ward when the manager arrives gets the blame.

This is a difficult issue, but I'm going to take a stab at it anyway. (And if I'm wrong, it's better that I at least thought about it than that I accepted possibly flawed conclusions.) Ducking responsibility shows nervousness and a lack of empowerment. A lack of empowerment stems from general distrust. I write about that more here. In short, I get the feeling that the emphasis is on protecting oneself and one's job (which is after all usually one's family's lifeline). The point of the job has been lost in the worry about basic survival, and that makes people selfish and helpless. Maybe selfishness and helplessness is rewarded more than doing the job is. Maybe helplessness looks inoffensive to those who don't like their colleagues to answer back.

A few years ago, in Cornwall, I knew a Hungarian lady who was a care worker - and an academic. She was doing the care work to fund the academia, and she cared a great deal about both. She mentioned at one time that it was difficult to get a new job not because of her inexperience, but quite the opposite. "They prefer naive young girls who don't know what it involves, because they think the rest of us will leave," she explained to me. "I know what it involves - it involves a lot of pee and poo." (She looked after adults with mental health problems.)

I mentioned flawed conclusions just now, and it is important to note that the ombudsman's report was based on ten cases. This looks like I'm making excuses, I know, but we can't judge the entire NHS on ten cases, nor on the four highlighted by the BBC. Reports like Joan Woodcock's, I think, are worth taking seriously (though not as all-encompassing) despite being by only one individual, for she has seen several decades pass and umpteen thousand patients.

Doubtless this report will be sprung on by circling vultures: private companies all too ready to take over; probably alternative medicine sellers who'll claim that their product "treats the whole individual" just as these public services evidently are not; and the government itself, to demonstrate that "the NHS is not working". But the NHS did work for a long time and in most cases it still does - good treatment just doesn't make headlines! Privatising would solve little or none of the above. What's so good about being "treated like a customer"? It only means a hierarchy will be created rather than efficiency - the simpler your disease and the fatter your wallet, the better care you'll get. And vice versa.

You may wonder why these issues worry a 28-year-old so much. It may be partly my medical family, but also because I've known long-term illness for myself - the weakness, the helplessness, the lack of knowledge about your future. For some time, I didn't know if I'd ever get better. I wondered if death would be the better option. Therefore, the thought of getting old and going to one of those care homes absolutely terrifies me - yet it's something that a great many of us will actually have to face.

The worst thing about a long-term illness is feeling useless, a drain on other people, unable to give anything, only to take. I'm really not happy when I'm only taking and not giving - and I don't say this because I think I'm a saint or something, I think that's actually what nearly everybody is like (it just makes you look silly or smug to say so). And I think it's something that we feel more the older we get, and the more we get accustomed we become to working and to looking after others. Who wants to rely on others for everything when they've lived 70 or 80 or 90 years and have worked hard and given a great deal for most of them?

It's peculiar how society is divided very strongly into two classes of people now: those who are working and those who are not. Those who are working are seen as the only useful ones. Those who are not are, frankly, a problem, and their numbers should be brought down. If they can't find a job, they're scum - they should do voluntary work not even for minimum wage, or starve. If they're not working because they're studying, they should pay vast sums - the assumption here being that the studying will only benefit them, not society as a whole. If they're not working because they're too young or too old, they are a pest and a drain because they're taking up other people's resources - and we must find ways to economise on this wasteful problem. Carers are treated shabbily enough. Parents are finding it increasingly hard to find somewhere to put their children while they work - and they're being threatened with very severe punishments if they want to look after their children themselves. (This sort of thing has been going on for some time - I recall there was a plan to punish parents who do not get a job as soon as their child turns one, and another once their child turns three, and another once their child turns seven, and another once their child turns ten. Plans generally come to nothing - in autumn 2007, as a trainee teacher, I was told that by autumn 2008 all schools would legally have to be open until 8pm for babysitting purposes, which of course by autumn 2008 had been completely forgotten - but the constant stream of threats and promises is a constant source of uncertainty, inability to plan properly, and doubtless waste and great stress.)

In short, if you haven't got a job, you're an affront ro the economy - and the ratio of people looking after you to other useless people like you should be as unequal as we can possibly afford.

But having a job versus not having a job is not the only definition of useful. Do you remember that children's book from the 1860's, "What Katy Did"? Katy's sick cousin Helen told her that "a sick person can be the heart of the house", and that they have a unique advantage: "she is always on hand". The Victorian era was a time of vast productivity, and it was a time of masses of different roles taken in society. (I'm not saying it was a time of universal good or that everyone was well looked after.) Why should we all aim to be in the role of the worker? - and if we are not, why is it assumed our only role is as a drain?

If we do not assume that the young, sick, studying or elderly are basically society's unwanted baggage - if we think of them as people who want to give, rather than simply want to take and who we "ought to treat with more respect", I wonder if things would change?

I had this idea a few years ago. It's an amateur idea, if that. It's an idea that you may simply laugh off. It's an idea that has so many possible legal pitfalls that I doubt it would ever get off the ground. It may simply be decoration rather than addressing a fundamental problem. And it might really annoy those who know more than I do. But if I don't share it we will never find out. Here it is.

What about combining care of the very old with care of the very young? For example, a residential care home which doubles as a children's nursery by day? Yes, there would need to be separate areas. But imagine how nice for both parties to have the other one around. The children would have someone to run to if they'd made an amazing tower with blocks, or if they'd fallen and hurt their knee. The elderly residents - who had a "daily activity" in one of Johann Hari's grandmother's homes - would have a bunch of ready-made grandchildren to talk to and listen to, to teach to read, to share their memories with. And they need not look after them all the time!

Fine, this idea has a great deal of untested personal bias. People tend to move across the country now - I never got to know any of my grandparents at all well before they died. But when I was little, I adored the elderly. I knew they had to be treated gently, but for some reason I was convinced they were all magnificent and saintly. I have also never forgotten a passage in Torey Hayden's story "One Child" in which she brings a mute four-year-old to meet a nearly-mute elderly stroke victim, who becomes far more "animated" as soon as he is in the room. Once I started office work, my colleagues only had to bring a little one in for me to develop a huge grin and, if the child wanted to talk to me, to have my full attention and have me make paper aeroplanes for them. Teaching and looking after kids brings me joy like nothing else can. Also I have worked at a call centre where the sick and elderly rang me to book hospital transport, and almost all were so very lonely. I know it wouldn't suit all young or old people. But it's an idea worth thinking about, perhaps?

As well as less in the way of wild promises, inconsistent and target-obsessed management, and general inhumanity, I would like to see people who need care being treated more as people - not just in terms of what they should get, but what they can do. It would have vast effects on self-esteem and morale all around. In my idea, the children's education and social development would benefit, as would I hope the elderly people's happiness (and if they get fed up they should surely be able to retreat to a private sitting-room!). It would hopefully inspire a lot more friendships and family links - perhaps children's parents would be interested in how the elderly people are doing, too. It would stop people being segregated into classrooms, offices or care homes where they only people they meet are others exactly like themselves, which would have to be good for generating mutual respect all round.

Wishy-washy-wisfulness, or a lot more radical than privatisation? I don't pretend this is a solution to all ills. I just think it might be worth a try. If nothing else, my Hungarian carer friend thought the idea had promise - and some of the adults she looked after were helpless in some ways, yet able to find some form of in-depth hobbies and even employment in others. If you work in healthcare, or just care - or even if you don't - I'd be interested to hear what you think.


Rob W said...

I must start with a caveat, because it's easy to sound heartless in this sort of debate: I think the vast majority of caregivers give great care and support, but.....

I refuse to instantly adopt a siege mentality and leap to their defence straight away in all situations, as many do. Because of the nature of the role they *must* accept that they will fall under an intense amount of scrutiny, and to be honest that's needed. Hiding behind an argument of "you can't criticise nurses" (as some seem to) is a recipe for hiding failure.

One of the representatives on Radio 4 this morning stated that they attempt to teach every complaint as a learning opportunity, and I agree with that. When your mentality is to be defensive against any criticism you instantly lose that ability, and also risk shielding:

a) the few bad eggs in the profession (let's face it, there's some in ANY job)
b) those that need more support and training
c) poor practice, culture and or/bureaucracy.

In short, I welcome the criticism because it's through that that we identify great practice and rectify poor practice, and the more people who accept that way of thinking, the less likely that a minority can hijack the report for their own political aims.

Alice said...

Thanks Chutzpah - I hope it didn't sound as if "leaping to their defense" is all I have in mind to do. There are instances of really poor care and even cruelty, I don't deny that.

As long as they can be responded to in the way you suggest, that is brilliant. What is less so is when the issue is jumped on vigilante-esque by the press and - as happened in my area a few years ago - the doctor held legally responsible committed suicide (never mind how many thousands of lives he could have saved in the future if he hadn't), or when a minority of cases are used as an excuse to condemn and even end public service generally.

Diana Smith said...

As someone who has lived for 3 years with the consequences of the reporting of Stafford Hospital I am keenly aware that there is nothing that the media like more than a simple story of evil uncaring nurses failing to care for frail elderly ladies.

Stafford has rather set the pattern on this. We have the amazing and terrible statistic that 400-1200 people died as a result of poor care. No body in the press ever stopped to question the veracity of this, and its source was so well hidden that it took me 15 months of detective work to discover that it is not true.

It has been impossible to quash these rumours so far because the pressure group and their friends on the conservative front bench dominate the media.

Stafford is not perfect, there were many things that needed attention, but it was never as it was painted by the press.

Many good staff at Stafford have left, because of the pressures. Those who remain have to deal with confused and sometimes hostile patients and relatives.

Millions, and yes I mean millions has been spent on the Inquiries, and I know that finally the Inquiry is beginning to get to the bottom of this. Take a look at the #pressreform blog and see article on Bill Cash.

I am fighting back. Have sent a major report to the Press complaints commission and the BBC regarding the misreporting.

It would be good if health care workers from other hospitals were willing to support this complaint.

Providing better health care means better communication between staff and patients. This becomes so much harder if the press are building divisions.

There are some people who would like our love affair with the NHS to end. It is up to us to ensure that it doesn't

Alice said...

Thanks Diana. http://pressreform.blogspot.com/ is very interesting, I recommend a read!

I am really sorry that such a thing has so poisoned all trust in the area. How can you stay calm enough to treat anyone, let alone respond sensibly to a complaint, in such an atmosphere?

I guess I wrote on far too broad a subject and should have made this several blogposts - what's being written about here is only part of the subject. Not that it isn't important - in fact, I expect it's the only thing written about here that isn't basically too abstract for anyone to have time on their hands to even think about at the moment.

(Still recovering from reading a great many posts from MilitantNurse and wondering how anyone survives being an RN! It's like being unable to turn away from a horror film.)