Nursing Times

 He misses the more fundamental issues around what might be going wrong in the settings in which older people are receiving care – acute wards in hospitals, care homes and in people’s own homes.  Leadership, organisational culture, skill mix and staffing levels are much more likely to be the source of poor care.  Hospitals with rapidly increased levels of acuity, shortened length of stay and reduced staffing levels mean that the proportion of qualified staff and expert leaders in elderly care in acute hospitals has been diluted.  By replacing staff with health care assistants who have received little preparation for their role in caring for acutely ill older people – the time available to provide for the basics of care has been eroded.  Care has progressively become more task oriented as caring activities such as feeding and washing have been delegated to healthcare assistants, an approach to care we were moving away from 30 years ago when I trained as a nurse.  Food, fluids and basic hygiene require time and detailed attention in frail and vulnerable older people when they are ill, as these are literally life threatening if neglected.  We need to reinvigorate the attention to these areas and put them centre stage.

 Culture and environment are also little discussed when reflecting on issues of poor care.  But organisational culture sets a powerful tone. Quality and excellence in care doesn’t come cheap but needs investment in great leaders who can give obsessive attention to the detail of what delivering quality means in practical terms.

 The Care Quality Commission report also gives examples of where providing for dignity in care fails.  This is sometimes a direct result of the architecture of hospital wards – where individuals may be forced to manage intimate moments such as going to the toilet or having a wash by the bed, behind curtains rather than in private.  Perhaps we should accept that even in new build hospitals privacy and personal dignity have been given little or no priority.  The problems are complex and systemic and won’t be solved by further regulating nurse training in the hope that we return to some mythical golden age.  Let our NHS leaders and politicians beware that given the current funding issues for the NHS unless we give this urgent attention the problem may only get worse.

http://www.bbc.co.uk/news/health-15388038

 This time though it was prompted not from reports of individuals experiencing poor care, but by one of our own leaders: Peter Carter, Chief Executive of the Royal College of Nursing, who we think went ‘off piste’ while raising the important issue of the growing proportion of the health care workforce providing care in hospitals and community services who are unregulated and untrained. Peter widened the debate to roundly criticise nurse training across the board, much to the consternation of colleagues who put enormous energy and dedication into preparing the next generation of nurses in Universities.

 Setting aside the issue of nurse training, which has been an inaccurate and unfortunate diversion, the very important question is ‘who is it that is delivering the poor care that we are all so concerned about? ’I ask ‘What national thinking is going on to determine the right balance of trained and graduate nurses to healthcare assistants to ensure that there is the right level of expert care and leadership in care settings?’;

 Currently the most powerful driver for this is cost, cost reduction being, as ever, the order of the day.  Accountability for getting the right level of staffing and a high calibre workforce that can set the organisational culture, provide leadership and deliver expert, compassionate and values driven and evidenced based care should be firmly with Chief Executives at Trust and NHS Commissioning Board levels as well as with the Minister of Health.  Let’s move away from vilifying individuals and offering crass analyses as to who and what is wrong. We must hold those in charge to account for setting the balance of staffing in hospital care home and community settings. The problem is an unintended consequence of driving a performance culture that allows costs and inputs to come before personal care.   Years of underinvestment and undervaluing nurses and nursing are the systemic cause of this complex problem.  Nurses and nursing budgets are the first to be cut when times are hard.  The move to an all graduate profession for nursing is one important element in a long journey to put the problem right.  But organisations and services are where poor care takes place, and newly qualifying nurses graduating from Universities represent a very small cog in a very large, complex engine.

http://www.nursingtimes.net/nursing-practice/clinical-specialisms/prescribing/major-study-acclaims-nurse-prescribing-success/5029754.article

http://www.pulsetoday.co.uk/story.asp?sectioncode=35&storycode=4129475&c=2

http://www.gponline.com/News/article/1070138/gps-urged-train-nurses-start-prescribing/

http://nursingstandard.rcnpublishing.co.uk/news-and-opinion/news/nurse-prescribers-are-popular-with-patients-ministers-told

http://www.zenopa.com/news/800528081/New_report_highlights_success_of_nurse_and_pharmacist_prescribing

http://www.thisisstaffordshire.co.uk/news/Study-shows-health-scheme-success/article-3543637-detail/article.html

http://www.medicalnewstoday.com/releases/224855.php

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http://www.nursingtimes.net/nursing-practice/clinical-specialisms/educators/degrees-will-build-in-values-to-underpin-and-ensure-good-care/5028834.article

Back then it was shocking that there were no national data about the number of people living in the UK with a cancer diagnosis or knowledge of the extent to which they were using health services and no data about their health outcomes other than how long they survived and when and if they died. A shocking indictment of decades of investment in cancer research.

We have been busy filling the gaps since then, we now have better knowledge about the issues for people following cancer treatment, how support might be provided and how we might move on from the current system of medical follow-up and replace this with a framework of supported self-management and ctructured aftercare services and approaches tailored to individual need. This is the biggest change in orientation of Cancer treatment and support in decades – a profound, and profoundly important cultural shift. We re-orientating services from ones focused solely on treatment no matter what the cost to a focus on recovery and supporting individuals returning to productive lines. This is part of the cancer success story that accompanies a doubling of life expectancy for the last 40 years.

I have spent the last 3 years thinking that we night not realise this change in my professional life, given the enormity. But today I listened to individuals from around the country presenting projects and initiatives that are putting in place this new approach and perspective at the Christie Hospital conference – Living with Cancer: Symptom management from treatment to survivorship. I am now convinced the revolution is definitely underway

It is good to see the issues discussed openly. I hold to my view – high calibre, well prepared nurses are pivotal to the quality of care in the NHS but, alone this will achieve little. Organisational culture and a leadership skilled in promoting high quality care centred around individuals, knowledge and skills and an organisation that promotes quality of care above all else remain key.

I have spent the last 2 days at the Nuffield Trust Health Summit #NTSummit with past and present leaders of the NHS system. Reform, redesign and performance management, at a fascinating time in the history of the NHS, were the predominant themes.

But I was struck by the preoccupation with the mechanisms of the NHS system by the assembled community. Debate around the extent to which it is in fact as ‘radical’ as the media suggests and the wisdom of taking the NHS through vast, costly, and poorly understood changes at a time of financial constraint – ‘It better be worth it’ was the main conclusion.

Absent for me was any real emphasis on core values, on the central and most important of issues – quality of care. On how quality is to be protected and nurtured in the new regime. Critical to this alternative agenda is not commissioning mechanisms or outcome measures but investment in a high calibre workforce and an organisational culture and reward systems that supports it.

Quality is a ‘cut-down’ concept referring to a deeply complex set of Pre-requisites that produce excellent support, productive care and health outcomes, valued by the individual who receives it. It is a pity that so little air time is given to fundamentals of quality, while so much emphasis is focused on a system, its hierarchies and the machinery of production.

I fear that caring, compassion and it’s corollaries succumb yet again to structures and careers.

We have called for this change to happen over decades. Even though we are the birthplace of modern, evidence based and data informed nursing, England has lagged behind Scotland, Wales and many other countries despite there being strong evidence to indicate that nurses prepared to degree level enhance the quality of care and are associated with better outcomes. All other professions in health including doctors, physiotherapists, occupational therapists etc have been expected to study to degree level as of right, but with nurses there has been deep ambivalence over accepting that to manage care and provide treatment in modern health systems requires extensive knowledge and skill. Nurses these days do many of the tasks that doctors performed 25 years ago when I was training to be a nurse.

Our new degree programme in Southampton is based around a curriculum designed to inculcate clear values from the first day. Compassion supported by a deep understanding of evidence based knowledge and confidence to recognise and speak out against situations where care falls below acceptable quality. Our students will benefit from studying with our world class researchers. They will learn alongside other professions – trainee doctors physiotherapists and occupational therapists and others as we believe this is how teams in health care increasingly work. They will have opportunities to study a second language and to study abroad.

We believe the training we have developed will produce unique nurses well prepared for the ever increasing demands of contemporary health care. As part of the process of assessing the quality of our new degree members of the scrutiny panel met a group of students from our nursing degree programme. One member of the panel, a patient, told me that having met the students she was so impressed by them, that for the first time in many years she felt the NHS, and vulnerable and sick people in need of care are safe in their hands. After the events of last week when we saw the publication of the Ombudsman’s report it feels like we might have produced a genuine response to the problems quality of care – a much better week for nursing.

http://www.nursingtimes.net/nursing-practice/clinical-specialisms/educators/university-to-train-all-nurses-to-degree-level/5026261.article

Over the last days since the report was published we have heard a whole range of inputs into why is this happening, what has gone wrong and what we should do about it.  My main thought is to warn against jumping to hasty conclusions we have heard a lot about whether we should train nurses differently, concentrate on the basiscs of care or stop nursing becoming ‘too academic’. This seems precisely the wrong approach.

What we need are high calibre and highly trained nurses who are supported and well prepared to uphold strong values around compassionate and person centred care, attending to the basics of what people need when they are ill and especially for those who are vulnerable such as frail older people.  These are expert tasks not just every day actions.  We need to detail the science behind what creates the circumstances to get this right.  The evidence is developing on what is required and is pretty clear – leadership, organisational climate and context, a skill mix that includes high calibre and expert clinical leaders and teams, adequate staffing levels and interventions into the health system that provide a framework for high quality care. Critical is organisation culture that upholds and supports the delivery of such care. I’d like to see the debate on this focus on what really needs to happen, especially as health care organisations – hospitals, care homes and community care teams will be forced over the coming months to cut back on the very resources, that is expert nurses who are best able to provide expert care, for the most vulnerable people in our health care system.

 Dan Bader has joined us from Queen Mary College, London as Professor of bioengineering and tissue health.  Dan is a medical engineer who is an expert in the science behind how pressure sores develop and in tissue damage, he will be establishing a new research programme working with nursing and allied health professional colleagues to tackle some of the most pressing and costly problems for the NHS – pressure sores and skin breakdown. He is currently establishing laboratory facilities at our academic centre at Southampton General Hospital and is looking forward to teaching nursing allied health professional and health science students at the University.