Category Archives: NHS

Audit, Inspection and Scrutiny: the three ugly sisters?

This popped into my inbox today:

“The need to drive up the quality of care for patients, whilst delivering efficiency and productivity, is a key principle for the NHS. As pressure on NHS finances continues to build, UKAS accreditation is increasingly being used as an effective way for purchasers and commissioners to demonstrate that they can achieve ‘more for less’.”

I felt a stirring of irritation. This blog is the result……….

I know organisations have to behave commercially and tick boxes in order to thrive. I spend part of my working life encouraging and supporting charities and NFPs to do exactly that, but without losing their heart and soul to it. It is possible. But as an old nurse (registered about a century ago) and vehement supporter of the NHS original principles of free at the point of need and paid for by the entire community I am increasingly dismayed by the passionless, sterile performance of the people tasked with – and paid handsomely for – managing “public” health services. I have seen patients become the enemy, clinical standards side-lined in favour of improvement on the balance sheet, kindness become irrelevant, and buzzwords and trends take the place of clinical and compassionate behaviour. Health and social services are scrutinised, inspected, audited, governed, examined, professionalised more than ever before and we still have Winterbourne, elder abuse, Southern Health (pauses to spit), frequent reports of casual abuse and cruelty (that we know of), and we will all know those “care” homes with a good CQC rating which pong and employ people you would not want to sit next to on the bus. We will all know of supported living services that are little more than one person institutions with little or no meaningful activity and engagement – or to put it another way, that warehouse people in units of one, creating the illusion of choice and a Life but deliver isolation and fear. We have seen Southern Health reduce victims and loving families to statistics and irrelevancies, destroying people in order to prop up a system that sucks and protect the very people who allowed and encouraged the system that killed people and fixed the blame on others, with lies, obfuscation and bluster.

Some inspection agencies, several tiers of consultancy and management and many more are too often yet another layer of “approval” or box ticking to chuck at organisations. Along with services like 111 –  a dangerous irrelevance that often removes much needed funding from frontline services for the return of reduced standards and increased risk –  they also create a cash cow for canny providers without delivering any improvement in clinical outcomes, or supporting real people with the very real challenges of everyday ill health. We seem to simply carry on increasing layers of approval, fresh hoops to leap through (some with fire) rather than examine very basic factors. Often the people creating those hoops are not clinical and have little understanding of how  things actually work in the real world. I keep hearing that we need more funding for this that and the other – I keep seeing a variety of groups being blamed for an ever increasing number of failures and deficits: currently GPs are getting a hammering despite being possibly the last group of professionals who should be blamed and who, along with dedicated skilled nurses have kept things going against the odds. Commissioning services is clunky, inappropriately targeted, poorly contracted and badly managed, which is a criticism of the process –  again often created by people who do not understand the real workings – and not the people who have to work with it. The competition itself reduces the capacity to develop and really grow health and social care support services because contracts are not only badly drawn and managed but are up for renewal so frequently it is impossible to invest in services and also make that holy grail of profit. Profit is not going to be the first thing to go.

I firmly believe in a skilled and educated workforce well managed and led and supported with career choices and pathways. I also firmly believe in holding organisations and individuals to account. I believe those can be delivered without the huge self-propagating self- perpetuating roundabout of new mandatory qualifications and accreditations, incompetent inspections, and without the workshops, consultancies, projects, papers, enquiries, processes, requirements and bottom feeding organisations that have sprung up around services that are actually intended to protect, care for and nurture us.

There comes a time when the volcano erupts, the boil is lanced, the pus drains and healing can take place. We need to recognise that the privatisation experiment which was trumpeted as the way to increase choice and competition which were equally being promoted as in our interests – I am pausing for the laugh here –  is a failure, delivering little more than profits for largely incompetent organisations and draining the body of the NHS of resources and talent. Choice is not what sick people want, overall – they want skilled professional care, close to home, delivered kindly by people they trust and with their involvement in the process. And answers if something goes wrong, with a meaningful apology attached. Dividing professionals and organisations with “competition”, asking for innovation when compassion is good enough, blaming good people for systemic failures and expecting mountains of assessments, graphs, justifications, and hounding good people for honest mistakes does not result in decent health and social support.

Have a look at this: Laugh and then weep.

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Brexit. Trump. Strictly. No, don’t click me away! Bear with.

Cards on the table, I don’t much like the tellybox. I watch, occasionally, stuff like Railway Journeys with Portillo, or that wonderful Canal programme with Timothy and Prue, but on the whole most of it passes me by. Most of what I do see is caught accidentally when the rest of the family are watching and I stumble into the room on my way somewhere else. However, I have become surprisingly interested in Strictly Come Dancing this last couple of series – maybe it’s because I remember watching the original all those years ago, usually with an altered state of mind which helped.

Bear with…….

This year has been in interesting year for anyone with half an eye on politics. We have, allegedly, seen a rise in the proletariat offering a bit of a slap to the people who have seeped and dribbled into offices of power and decided they know best. Not only that they know best but that the proles know nothing and need to be kept in their place. Our place. To that end, arguably, Education and Health, and to a large extent the Criminal Justice System and Housing, have been morphing in recent decades, leaving behind much of the social construct and responsibility that most of us value and developing a profit motive that no longer has to try to hide. Priorities in socially important organisations changed of necessity – it was do or die –  and in part that has been supported passively by people still believing that someone with a lot of money and a private education knows better than them. Pair that with the desperate need of many to simply keep body and soul together leaving little time to be involved in much else and a consistent lowering of expectations and we have a perfect storm of passivity and fatigue that allows people who do have the time and money (and the networks developed at school and Uni and by family connections) to buy a pathway into power. I mention no names…….

And then came 2016. Hands up who approached 2016 thinking “Thank Goodness 2015 is over, what a year, it can only get better”…..? Yes, well that went well, didn’t it? Apart from lots of lovely people dying who had created my history and the musical and artistic backdrop to my youth, we also had Brexit and Trump. Divisions created deliberately by the powerful to conquer the masses led to the very public murder of one woman, an increase in the confidence of people with shameful attitudes, a legitimising of all kinds of isms from ageism (the older generation have spoiled things for the young/the young don’t understand the issues) through racism (go back to where you came from/who will you blow up next) and a general atmosphere of mistrust and hatred. Conversation was replaced by brick throwing and chanting, voting was seen as an act of defiance rather than an inalienable right and duty and more people voted for Brexit than at any General Election for years. Public dissatisfaction with politicians who fiddle expenses and despise their electorate was having some practical results. Trump had already hopped onto the bandwagon and shamelessly – alongside some of his opponents and supporters – traded insults and lies rather than debate and detail, whipping up his gang to hatred of others, violence, intolerance and a lack of facts. Taking mansplaining to a whole new level, and behaving publicly in a way that many parents would justifiably have slapped their children for, he set new and deeply unattractive guidelines for public debate and demeanour. In both of these events we witnessed the powerless grasping onto something over which they believed they had some control, a new experience for many. In reality the power and control remained exactly where they already were but the illusion of influence was conferred, more expertly in some areas than in others. That precious vote, hard won by ordinary people over the years, wrestled from the wealthy and powerful and certainly not given freely by them, was being manipulated to support the very people who stood to gain most. And that, Ladies and Gentlemen, is politics in the 21st Century. Ordinary people are encouraged to think they have had enough of the elite – by some of the elite – in order to get them to vote for the elite.

But something did happen. The idea of sticking it to the elite has taken hold. The concept that perhaps people can make choices, sometimes dangerous or wrong choices, and define their own reality and outcomes and live with the consequences is becoming clearer. And so we arrive at Strictly. I told you to bear with. Ed Balls joined the Strictly dancers and immediately gained the publics support for dancing badly, but with charm and warmth. The pubic enjoyed his efforts and his ineptitude, his determination to do his best and move forward – they liked it much better than some of the other dancers who danced better but were less appealingly human and had less distance to go to dance well. Someone who until recently appeared as part of the elite was shown to be Like Us. Not only Like Us, but likeable and funny. He charmed. The judges were ghastly to Ed and that just increased his popularity – they gurned when he danced, were outright discourteous, were way less encouraging to him than the other “better” dancers and generally behaved like, well, like the elite. Clearly they are the experts, clearly they are dancers, but their unpleasant behaviour rendered that immaterial – we liked Ed because he wasn’t an expert and wasn’t elite. We didn’t like the judges being smug and telling us what to like and what not to like. We Brexited them. We Trumped them. We voted in droves for the Little Man. Apparently. Well, job done. Ed is rehabilitated and the People have spoken. He has worked hard and redefined his place in the public eye.

Quite a few of The Elite are chums of mine. Quite a few of The People are chums of mine. I like them all – I think there is a little bit of fabulous about everyone, without exception. Their politics are not what I admire about them – if they charm me and make me laugh, if they have a brain and a heart, are kind, and hold a conversation well that is what I admire. What they do in the ballot box is not my business. What is my business is what happens when the votes are counted and policy decisions are being made. As someone who has worked for years in health, justice and social care and across all the sectors, and as a school governor, I have seen how public policy impacts actual people. Left and Right are almost irrelevant as long as socially important organisations and services remain at the whim of people many of whom will say and do almost anything to sit in a seat of power, many of whom have no meaningful experience of the departments they lead ( I am sure you know what I mean and who I mean……), and who potentially change direction regularly every few years. When there is actually a direction to change and not just a dogma to follow.  While we have no available Intensive Care beds for children anywhere in the country, while nearly 9,000 people slept on the streets in London alone in 2015/16 – and that is only the recorded figure – and 57,750 households were accepted as homeless and in ‘priority need’ in the same year, a six percent rise on the previous year, while mental health services are randomly delivered and under-funded and a false economy as so many people bounce around the expensive system, while almost as many people leave prison unable to read as entered it (this is changing, thank goodness, thanks to some fabbo people, but so slowly), while people with a criminal record are routinely excluded from jobs and housing denying them the opportunity to desist, while all of these things and more are happening Left and Right can argue until blue/red/green/yellow/purple in the face but it will remain a disgrace and the responsibility of all of them. And all of us.

There are some properly decent people in and around government and in and around some of the organisations that develop and deliver services, people who actually want to make a difference and not a fortune. I insist on feeling hopeful that the vote for Brexit – and Strictly – is an indication of the start of increased popular involvement in government. Whether or not I agree with outcomes upon which people vote does not matter – it is up to me to make a case for my view and debate properly. If votes go a different way to the one I would like I still rejoice that democracy has taken place. We have become a tad complacent in recent years, the freedoms and opportunities that have taken so long and so much painful sacrifice to attain are at risk. That complacency has allowed bad practices to slip under the wire – without some darn good journalism the expenses scandals would have remained unknown, for example, or at the least unremarked. Our inexplicable faith in people in positions of power, supported by the anaesthesia of media dependence, has let us take our collective eyes off the collective ball. My optimism tells me that people are perhaps willing to become more engaged and knowledgeable about the things that will affect their lives and less tribal in their allegiances. Brexit and Strictly both cut across most demographics…….

So, vote for Strictly! Vote in your local and general elections! Talk to your MP, find out what she or he actually thinks and don’t take it on face value – challenge, probe, question, scrutinise. And crucially, tell her or him what you think and what you expect of them. Own outcomes. Learn to Salsa and wear some fancy clothes. Dance and vote like no-one is watching.  And remember that T Blair is creating a global organisation to combat populism  – that’s you and me – and promote globalism – the thing that fills his pockets. We must be becoming dangerous……….

Look at me

I saw a few posts on social media this week about people who ignore their children in order to check their phones and messages…..you know the sort of thing, a picture of a fed up child and a parent staring at a screen. In my study (I am on the fourth floor and commonly known as the Mad Woman In The Attic, not without some justification) I watch parents taking their children to school and some parents even have earphones in – blocking out not only the wonderful sounds of the morning, birdsong and breezes, but also their children, who stump along next to them glumly, often trotting to keep up as the uncomprehending parent  marches ahead in order to get that task out of the way and get on to other important things such as staring at a screen and drinking coffee. It makes me feel sad…..

It also makes me angry that we are still at this point in our evolution. For the past thirty-plus years I have been attempting to inject humanity into health and social services on different levels, since the horror of student nursing (about a hundred and fifty years ago….)  when, on my first mental health ward for elders (the clue was in the shorthand title: PsychoGerries) I trotted along for my first day to discover a shabby-coated and smoking staff nurse standing – slouching – in the centre of a semi circle of commodes on each of which there was a naked elder. Both men and women were lined up together for ritual and casual humiliation. After a brief pause to get my breath as I stared at him I sent him home (well, there were a few well chosen and short words as well) and along with some chums set about restoring a little dignity. At every stage, for years, I have seen that same ritual and casual disrespect and humiliation handed out to all and any people using services by people who, if you met them elsewhere would probably seem like decent human beings. From elders having crap food shovelled into their mouths by smoking and grubby “carers” to people with learning disabilities ignored and belittled for being who they are, not even allowed to choose their own bedtime, their own food, the people with whom they will spend their days – their lives.

Don’t get me wrong: there are some brilliant support people, some fabulous organisations who strive to be good, to deliver humanity in their services and campaign for change. I know, and have worked with, many fab people who actually care and understand what that means (ie that it isn’t just about smiling a lot and nodding, but it is about taking risks, liking and respecting the people around you and understanding that each of us is individual – and encouraging that). But in the grand scheme of things these people are too few, and the others are tolerated because of where we are in our evolution. Which takes me back to where I started.

Being with people – supporting people, caring, whatever word you use, and the words matter because you will behave in a way that the words expect – IS the point. The things we do, taking children to school, supporting someone to eat, going to a gig with someone, supporting someone to put their clothes on, shopping with someone, they are all component parts, each as important as the other, as important in how we do them as well as that we do them at all. Those grubby “carers” shovelling food into someones mouth are indeed performing the task in their job description but their main task – of being with someone and having that relationship with someones humanity, their person-ness – has been lost. How much more time and effort would it cost to look at the person in front of them and see their person-ness and be kind? But that kindness is by and large not factored into how we commission, deliver, train for, reward and recruit to support services. Our task oriented focus takes us from task to task, KPI to KPI, box to box and target to target. When was the last time you saw the word “kind” in a job description……?

I remember – and I wish I could forget – watching a “carer” stand up, walk over to an elderly woman with dementia, and without a word roughly haul her up and out of her chair because it was “toileting time”. I sent a nurse home one night years ago because as we were nursing a comatose dying woman in her bed the other nurse leant over her – right over her – and said quite audibly to me “I don’t know why we are doing this she will be dead by the morning.” Casual cruelty, thoughtless indignity, the view of people as lumps of meat to whom we have to do things in order to earn a pay packet. Hauling ourselves and the people we support from task to task as quickly as possible…..for what? That task is a means to an end, a conduit through which we can nourish and nurture the relationship – it is the means, not the end.

It is that corporate and individual refusal to see people as human, as individuals, that allows learning disabled people to die in hospitals they should never have been in far away from the people who love them and allows the people who allow it to happen to bear no meaningful consequences.  It allows elders to be warehoused in buildings from which they will never leave until they die, who will never again feel the breeze on their faces, hear the birdsong or the sea, have someone look them in the face and hear what they are saying, be useful, be heard. Be a person. Have fun. If we are not having a little fun along the way what is the point?

Please take some time to look at the links here. Stay Up Late is a brilliant grassroots charity promoting the right for people with learning disabilities to have a choice about how they live their lives. That it is needed at all is telling.

The more difficult read is the piece about assessment and treatment centres. Read it and weep. And then sign up to the 7 days of action. Please

And please read about Connor Sparrowhawk and his phenomenal circle of support. Even after his avoidable death the people responsible have had little or no consequences, even after compounding the pain by denying wrongdoing, doing a bang up job of saving their own skins, and reducing the humanity of everyone involved. Shameful. Painful. And his Mother has responded with dignity and energy – I listened to her on the radio a few months ago while I was driving and I had to pull over and stop because I was weeping too much to continue driving.

Home

https://theatuscandal.wordpress.com/2016/04/20/natural-causes/

https://www.opendemocracy.net/uk/shinealight/clare-sambrook/on-connor-sparrowhawk-s-avoidable-death

The “care” industry is regulated more now than it has ever been – there are audits, documents, inspections, investigations, inspectors, investigators, commissions, boxes to tick, all manner of things supposed to keep us safe. And yet the abuse is still there, as open and filthy as ever. Safety is not guaranteed – and anyway, is safety the most important thing in life? Isn’t fun –  and autonomy, and independence, and risk, and loving and laughing, making mistakes, and pain and heartbreak  – as important? Aren’t those things the things that make us human? Those safeguards will never take the place of kindness and humanity, of seeing the person in front of us and respecting them just for being themselves. Let’s try that – and owning it when we get it wrong – for a while and see what happens………

 

 

 

 

 

 

 

 

 

 

 

 

 

Food Glorious Food?

Sharing meals allows us to come together and spend quality time with each other. It increases communication and understanding.  How many of us had our first experience of another culture through food? And coming together to prepare and eat food is part of many rituals and traditions. Food plays a big part in faith and in worship. When one shares in the Eucharist, it is said to be a  sharing of Christ’s body and blood, and worshippers are reminded of their responsibility to share all our meals with others. As St John Chrysostom once said, “You have tasted the blood of the Lord, yet you do not recognise your brother…You dishonour this table when you do not judge worthy of sharing your food someone judged worthy to take part in this meal.” Most faiths and religions have food rituals, most cultures have food rituals and norms. Food is significant. Food rituals – cutlery or lack of, how the food is produced (is it Halal? Organic? Vegan? Kosher?), how it is presented, how it is eaten – matter deeply to us all. The only people for whom those things no longer matter are the hungry, and even then I have known seriously hungry people refuse non-kosher or non-vegan food. So it is quite simply that important.

So…..

How many times recently have we heard about nurses now being expected to “feed and wash” patients for a year before they train? How many times do support workers and health professionals refer to “feeding” their patients or clients? The act of eating is reduced, for some, to the passive “feeding” offered by “carers”. It is reduced, for the care-givers, to a task to be got out of the way before the serious business of training, the important job of “nursing”, can be carried out. This simple attitude reduces human and humane care giving to the status of animal welfare. Now, let us acknowledge that there are similarities between the two, and animal welfare is very important. But in offering to care for and support other human beings we need to respect and acknowledge their humanity, and one of the few things that identifies humans as distinct from other animals is the development of specific and identifiable social rituals, especially around food, and the food rituals often define what we are as people: they indicate and specify how we live, what we believe, what matters to us.

The attitude that accepts us saying we are going to “feed” people when what we should  mean is that we are going to help them to eat or support them to eat is the same attitude that allows nurses and care givers to say things like “I have done Mrs Brown” when they mean they have helped or supported Mrs Brown to wash, or dress, or change her colostomy bag, or any of the other deeply personal, uncomfortable and intimate things carers do for us.  Those words, casually used and casually accepted, reduce our collective humanity, remove our independence. They remove the respect for our humanity that we properly expect our nurses and carers to demonstrate. They allow the casual neglect – and even the active cruelty – that we have seen in Winterbourne and at Stafford, and the many other places that have not yet hit the headlines. How can we pretend to be surprised by those events when we use the words that support the attitude of neglect and cruelty?

The words we use define how we behave, demonstrate how we think.  Let us challenge the use of words that encourage patient-passivity such as “feeding”, let us encourage the words that support active care such as “supporting, or assisting, to eat”. The former gives us a picture of food being shovelled into a patients mouth as a “carers” task, the latter gives us a picture of  someone in control of their food, being helped to perform their own task.  Notice the difference between “bathing” someone and “helping someone to bathe”.

When we become vulnerable through age, illness, disability or other reasons we often lose the option of privacy or dignity only because of the attitudes of the people tasked with supporting and assisting us. There are many discussions about why care can be poor, and often the poor wages are cited. And that is a factor – pay peanuts and you get chimps, and low wages do not reflect the importance of the job – but there is never, at any price, wage or  reward any excuse for reducing another persons humanity, for dragging away another human beings respect and trampling on their dignity. Individuals are responsible for their own behaviour and we should expect people recruited to care and support to behave properly – but the modelling of those good behaviours will flow from the leadership. If the people leading the services and the organisations do not demonstrate the crucial behaviours that indicate respect, humanity and the support of autonomy and independence for all then the people following those leaders will have no incentive to do so.

If you offer someone care and support, please, feed your dog but support your patient to eat.

An old blog of mine…….strokes, death and the aftermath.

I was looking through some old postings and re-read my blog from over a year ago, written when my Mother was dying as the result of a stroke. I need to finish the blog – it was interrupted by the need to be with my Mother, and then  to repatriate her and arrange the funeral, and then to have a period of planned insanity. I will complete it soon. But I wanted to share it again, first, because it is so different from  how  I usually am, and the many responses I had to the blog when it first appeared made me realise that we are all “different selves” when confronted with death and suffering, or with neglect and idiocy. And I was made forcibly aware that it doesn’t matter who we are, what we do for a living, how much money we have, how bright or otherwise we are, or who we know – at heart we have that turbulence and pain right at our core and it is how we manage it that matters.

http://daughterofastrokepatient.wordpress.com/

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