Wednesday, 24 February 2010


There's concern, rightly, that the Mid Staffordshire NHS Trust let people down spectacularly.

The inquiry has released a lengthy report on this, with evidence from over 900 patients/carers as well as staff from the hospital.

His headline message is, dishearteningly, not surprising. It is that, "The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care."

The grim care described is not that different from some of the patients I've seen in our local hospital. Some of the ignored dementia patients rolling around in faeces, and patients left with food out of reach, is exactly the same as poor care that I have seen in our acute Trust, up the road. Therefore the Health Secretary's assertion that, "This was ultimately a local failure," does not ring true. Sadly, I'm more convinced that the president of the Patients Association comment has it nailed with, "The scale of problems at Stafford might have been unique but failures in essential nursing care are not."

If you don't have enough staff, you can't deliver quality care, but heck you can't even deliver acceptable care. How viable is it for ward staff to close the doors and refuse admissions because they feel it's unsafe to do so? Notionally they're obliged to, since the NMC and GMC require nurses and doctors to provide safe care. We've been that bold in community teams, refusing referrals because we can't provide safe care. You wouldn't believe the trouble that got me in to (being summoned to explain this to the great and the good, which was incredibly illuminating for them!) but I still do it (and have done so twice this week already - we deliver good care and can't accept work then deliver substandard care) but it's only working because the team's convinced it's the right thing to do.

Managers have had to accept this. Managers can direct systems, they can't manage direct clinical care. A manager can't say that I have to see Mr Smith and tell him blah and prescribe drug X for him at this dose. Sure, they can generate a framework for me to see patients and can force a Job Plan on me determining where I am and when I'm there, but qualified staff are professionals. Rather than technicians, undertaking what we're tasked to do, that means we're responsible for making decisions on the specific clinical care of the patient in front of us. Managers can't meddle with that. This empowers clinicians, enabling significant leverage in service delivery. We can do what's right for our patients, which can mean suggesting referral to another provider since we aren't in a position to provide appropriate care.

The NMC Code requires nurses to advocate for their patients. Do nurses advocate that admission to Ward X is unsafe? Do nurses allow admissions when they feel the ward's inadequately staffed/resourced to provide appropriate clinical care? They do so usually because nursing hierarchy is notoriously hierarchical and it's seen as unthinkable to say, "No!" to a boss. But when the whole team says, "No!" and it's the Consultant writing the letter saying we'd love to provide care but we're not in a position to do so since such care would be unsafe (and we can't accept then deliver unsafe care), shifting it from a managerial to a clinical decision changes the problem (and solutions) significantly.

Team work. It has to be the way forward.


Dr Grumble said...

I have always thought that it is a very curious thing that ITUs sometimes refuse to take patients because they don't have sufficient staff. In fact this used to be very common. What is the consequence of this? The consequence, if there is no other bed available, is that the patient gets managed on an ordinary ward. The ITU people say that they cannot provide an acceptable standard of care commensurate with their status as an ITU and therefore they won't take the patient. Yet if they somehow managed and had nurses running between patients the patient would still be much better off than under the care of Dr Grumble on the ordinary ward without the necessary resources. Taken to its logical conclusion Dr Grumble could say that he can't provide an acceptable standard of care and send the patient back to the GP. That's not realistic. We are trained to manage with the resources we have and we do our best even if it is not good enough. There really is no alternative.

It can though be a slippery slope which leads to nurses ignoring wailing patients as a coping strategy instead of blowing a whistle (which we all know is never the option it might seem to an outsider).

The Shrink said...

With ITU it's tricky, because the resource (or the building with all the necessary kit) isn't easy to magic up.

With safe in-patient wards I think it's different because the resource in deficit is staffing. Staff can be allocated relatively promptly, if it's paid for. PbR can generate huge surplus income (the bit of Consultant Physiciany new patient/follow up clinic work I do for the neighbouring Trust coins it in big time for them).

I genuinely think that rather than colluding in provision of poor care, or whistle blowing (which as you say, isn't going to happen/work), not delivering on activity that generates income for a Trust results either in that activity going elsewhere or in the Trust providing resources to do the work.

It's not a perfect solution, but using clinical decision making as a team to effect organisational change can be a powerful contribution to the process of effecting enhanced resourcing.

Nurse Anne said...

Do you really believe that the nurses haven't already thought of and tried this?????????????????

Come on now!!!!! Of course we have.

They bring the admissions anyway.

And you get threatened with formal disciplinary action for trying to refuse.

My colleague was left as the only RN on a 35 bed medical surgical ward last year. They tried to send her an acute admission. She told them no way. High level management was notified by the site manager and they phoned the ward from their homes (this was a weekend) and absolutely screamed at her. She was told in no uncertain terms that if she tried to refuse admissions she would be gone.

Why they were on the phone screaming at her the site manager just brought the patient up and dumped him in a bay. The site manager did not say a further word to the staff nurse. He just dumped the patient and left. The nurse found this new patient in her bay awhile later.

This is typical. She did the incident report and of course it was ignored. She also phoned the matron at home and was told "what do you want me to do." This was about noon time and only about 1/3 of those patients had been seen by my colleague at that point and had their 0800 drugs.

Later in the day they sent her a 17 year old cadet and said "there you go, now you have more help".

The cadet sat at the station on facebook.

Spirit of 1976 said...

I like the idea, so long as the consultants and senior nurse managers involved will actually back it. Sadly, as Nurse Anne's example shows, if an individual staff nurse tries it they'll simply be steamrollered into submission.

The Shrink said...

Nurse Anne, I'm with you that a staff nurse on her own, with an unsupportive/tyrannical manager above her, is buggered.

The only way it can work is if a clinical team, rather than individuals (or one professional group, like nursing staff) take the same view.

Can all medical and nursing and OT and support worker and social work staff all have it wrong? Either way, if the entire team don't accept a patient and the Consultant puts in writing that they're not accepting the patient and why, the managers can move people where they fancy but they're struggling to direct clinical care.

For a manager to say, "Do this or you're gone!" is of course unlawful, but that doesn't stop oppressive nursing hierarchies which, sadly, exist firmly within our neighbouring acute Trust too :-(

pj said...

Are nursing hierarchies more oppressive than those in medicine? I doubt it!

The collusion of medical seniors in poor working practices is, IMHO, a large part of the problem with the NHS at the moment.

On my first day as a house officer the consultant spent 30mins spouting a tirade of abuse at me for something the previous house officer I had taken over from had done (and which, to be fair, wasn't her fault either). At the end of the tirade the consultant admitted, 'I know it isn't your fault, but...'

There is no fucking 'but', shitting on those beneath you is a venerable tradition in medicine and is tolerated in a way that would be unthinkable in other walks of life (just like the constant low level sexual harrassment).

Dr Grumble said...

The reality is that in the NHS you can never have everything you need to do your very best for the patient. The consequence is that we have all been brought up to manage with what we have got. If you are in an ITU and have empty beds for lack of money for nurses and you refuse to have the patient (which they always do) all that happens is that the clinical problem is forced onto others with even fewer resources. The same happens with other services. If a psychiatric department downs tools because they are too precious to manage without all the resources they would like then the problem is forced onto a hapless GP or people like me on the general ward. Downing tools only works if you can force your patients onto somebody else who has to muddle through and inevitably does an even worse job than you would have done despite your resource problems. Now if, like me, you are at the bottom of the pecking order you cannot down tools. If a patient with meningitis needs to be admitted and you have not got the nurses you cannot tell the GP to manage the patient at home. So it makes me very angry when I get landed with patients who would be better off in a specialist service who feather bed themselves and refuse to take patients unless they have resources for a five star service. It is just not something you can do if you work on the front line. My feeling is that whichever line you take you might run foul of the GMC.

The Shrink said...

Dr Grumble, I whole heartedly agree that we have to practice with finite resources, so frequently will be frustrated when we've the will to deliver appropriate clinical care but don't have the resources.

Turning away work can't be done to be churlish or impetuous. To my mind it's done when :
1) Patient safety is very significantly compromised
2) Resources are inadequate to deliver acceptable clinical care almost all the time
3) There's a realistic solution that can be readily implemented

Only when all 3 circumstances have coexisted have we entertained declining referrals.

Of course, I am in the position that within 45 minutes you can drive to one of 4 other towns/cities who can provide alternative care. 2 are financially fraught and are gasping for more referrals.

In practice, therefore either patients are referred to a unit that has capacity, or our PCT/Trust fund us to do the work. To date, some work's gone to neighbours whilst we've talked it through in a timely manner (I meet commissioners every month and we've very good relations) then we've managed to gain funding to develop our services and absorb the activity locally.

For me, it's better than colluding with a poor system. It we accept poor care, then by definition that's acceptable. We accept it. That irks me.

I'd not want to suggest we fail to provide clinical care in a pique. I'm suggesting it can be done to promote better patient care, support teams and develop better resourced services. It's worked in my corner. It's not a negative event when we're having a tantrum and downingtools, it's part of a positive solution.