Thursday, 13 October 2011

Is there a doctor on the ward?

The findings of the Care Quality Commission in relation to the appalling treatment of old people in many NHS hospitals will come as no surprise to many families. If you’ve visited anyone on a geriatric ward recently – as I have – the sorry story of neglect and disinterest will ring an awful lot of bells. Unfortunately, you can ring those bells for 45 minutes and nobody takes the slightest notice.

There are a number of fundamental problems at the heart of the UK’s National Health Service and they have nothing to do with the total amount of money in the system. Lack of cash can exacerbate the problems, to be sure, but the problems actually revolve around culture and organisation.

The first thing I’d observe is that many hospitals have the right procedures and approaches in place. They can show you paper policies which sound entirely reasonable and forward-thinking, but they struggle to put any of them into practice on the wards.

A few months ago, I conducted a survey of London NHS Trusts under the Freedom of Information Act to find out how many of them operated what they call ‘protected mealtimes’. This marvellous idea is that patients should be left in peace while they scoff their grub, but if you’re elderly or confused, maybe you forget that someone’s left you a plate of food. Perhaps you don’t even realise you need to eat. Many of the nurses and auxiliaries simply can’t be bothered to help, while others are under severe time pressure with a list of tasks to perform and are unable to spend five or ten minutes spoon-feeding nutrients into the nearest OAP.

Who takes up the slack? Why, the patients’ relatives of course. They are usually committed to the wellbeing and recovery of their loved one and will happily assist at mealtimes. Except... err... they’re not actually supposed to be there. Mealtimes are protected, you see?

Now, here’s the interesting bit. When I surveyed the hospitals, they all came back with reams of policy documents about ‘red tray’ systems to identify the poor eaters and told stories about how flexible they actually were in allowing relatives to stay on the wards and help with the feeding. But my real-life experience of a south London hospital earlier this year was that we were not wanted on the wards at mealtimes. The well-meaning policy blurb means nothing to the people who are slapping trays of food down on tables and doing a runner.

This is a cultural problem. There is no real leadership on NHS wards and an incredible amount of drift. Doctors are a big part of the problem because they are never actually there. There’s a way of working – which dates from the year dot – which says that the medics do daily ‘rounds’, although no one ever knows when they are. The staff members have a very vague notion and the patients and their relatives have no idea whatsoever.

Typical scenario in an NHS ward: an elderly relative has a fall and breaks something. She ends up in a geriatric ward for a couple of weeks, until such time as she has recovered well enough to return home. The family comes to visit. Has she been seen by a doctor, they ask? She can’t remember. Surely a member of staff will know? Unfortunately, they’re vague and evasive. The doctor will be coming tomorrow morning. Everything’s fine. Granny’s having her blood pressure monitored every 15 minutes by someone who’s been taught the skill in the same factory that Charlie Bucket’s grandfather learned to screw lids on toothpaste bottles.

Charts of readings and vital signs are left lying around, but no one ever interprets them or acts upon them. What medicine was our elderly patient taking before she came onto the ward? One of the tablets has been stopped and another one’s been added but no one will explain why. Perhaps no one really knows. It was the doctor, you see.
So, when is the patient going to be coming out? Who can tell? It may be tomorrow. It may be the next day. She’ll need to be seen by the doctor. And when’s the doctor coming? Jesus Christ, are we getting a sense of déjà vu here?

Sometimes when I walk into these places, I really do think that I could make a difference in 24 hours. Communication, communication, communication. Between the doctors and the nurses. Between the nurses and the ancillary staff. Between the staff and the patients. Between the staff and their relatives. All people want to know is what the hell is actually going on.

Major improvements could be made if people simply talked to one another and there was a clear record of what had happened to each individual patient – perhaps in some kind of easy-to-read electronic format. But in itself, this isn’t enough. It doesn’t get over the problem that many of the staff are poorly motivated and lack proper supervision. There’s no easy fix to this and it’s impossible to deny that the jobs are poorly paid and unattractive. Leadership has to play a critical role here in terms of increasing motivation and a sense of purpose among the nursing and support teams. Someone needs to be there to observe and correct poor practice and we also need to provide proper recognition and reward for those people who are getting things right.

The current management of NHS wards is grossly inefficient and leads to so-called ‘bed blocking’. People are often kept in the hospital for days and days unnecessarily, as staff wait for doctor’s assessments, meetings of interdisciplinary teams, visits from social workers and occupational health experts. Until this bureaucratic and uncommunicative culture is tackled, the sad stories of neglect and indifference will continue.

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