A scathing report says the NHS has failed the elderly. Sheena Hastings talks to a leading health educator about what can be done.
“DISMISSIVE attitude...apparent indifference...to deplorable standards of care...dehydration and poor nutrition....inadequate pain relief...poor communication... an ignominious failure to look beyond a patient’s clinical condition and respond to the social and emotional needs of the individual...”
No one wants to hear such comprehensive lambasting of elements of their profession. But health ombudsman Ann Abraham pulls no punches in a report that has reprimanded health professionals for “neglecting fundamental aspects of care for older people, including food, water and cleanliness”.
She catalogued a “harrowing” array of failings in hospitals and GPs surgeries, which left patients suffering unnecessary pain, indignity and stress. The findings were based on complaints referred to the ombudsman’s office after they had not been resolved at a local level. The 226 cases she investigated involving people over 65 during the last year included: a patient taken on a long journey from hospital to care home strapped to a stretcher soaked in urine, bruised and dressed in someone else’s clothes held up by paper clips; a patient left dehydrated for so long that his tongue “was like a piece of dried leather”; a woman who was not offered a bath or shower at all during a 13-week hospital stay and was left for four days with an open wound on her leg; the turning off of a man’s life support machine by staff, despite the family’s request that it be kept on until they arrived.
Unannounced inspections of wards in 100 hospitals will start next month to assess “dignity and nutrition” for elderly people, says the Care Quality Commission in response to Ann Abraham’s report. Each inspection team will include an elderly person who has experienced hospital care.
The Royal College of Nursing called the report a wake-up call to people working in the NHS; the Government said it exposed the urgent need to update the health service and challenge poor practice; and the chief executive of charity Age UK said it was difficult to imagine our society allowing such indignity and neglect to be suffered by any other group of patients. Ms Abraham said the shocking litany of poor care exposed the gulf between the principles and values in the NHS constitution and the reality of being an elderly person in the care of the health service today.
Inevitably much of the criticism lands on nurses, as the health professionals whom patients see most of during hospital care. This is not necessarily fair, says Sue Bernhauser, Dean of Human and Health Sciences at the University of Huddersfield, a career which led her to become head of Nursing and Midwifery at the University of Brighton before taking up her present job six years ago. She was, along with the great patients’ champion Claire Rayner and others, a member of the Commission on the Future of Nursing and Midwifery which reported its findings and recommendations for high quality care in the NHS to Gordon Brown a year ago. The coalition has not yet responded to that report.
“Claire was worried that nursing had moved away from the bedside, based on the experiences described in letters sent to her as head of the Patients’ Association,” says Ms Bernhauser. “I am very distressed by the Ombudsman’s report, as will all the nurses, other health professionals and the health educators I know. The majority of nurses get out of bed in the morning determined to do good not harm, but as the one health professional that look after patients 24/7, with the greatest opportunity to make people feel good about their experience and alleviate suffering, nurses also attract more complaints than the other professions.”
Her own long experience as a nurse told her that for every one complaint formally voiced there were “probably five more” that were never formally made. “I remember one man saying that it ‘wouldn’t to do to complain while his loved one was still a patient’. Bernhauser doesn’t believe that any weaknesses which may exist in nursing practice in some places can be blamed on the move towards degree level education for nurses. “Care and intelligence are not mutually exclusive. As health care becomes more complex there’s a need to have more technical skill, but this goes alongside responsiveness to patient needs and treating the person as an individual. The tragedy would be if we did not take these case studies highlighted by the ombudsman and learn from them, examining what we do and asking if the training we give equips nurses well enough in every respect”.
Partly due to recession and unemployment, says Bernhauser, applications for the 150 places in nursing training at Huddersfield University have risen by 70 per cent this year, meaning there are about five applicants for each place. She believes the selection panel for nursing degrees is becoming ever more adept at choosing the right candidates who are not only intellectually able for the course but also show that they already have the empathy necessary to develop a high level of bedside skills. Communication is a key area of training that needs to be started early on.
“A nurse might be accused by a patient of having a ‘dismissive attitude’ if they ask her for something while she is in the middle of helping another patient and says ‘I’ll do that for you in a minute...’ but never comes back. She needs to explain a bit more about why she can’t do it right now, then remember to come back as soon as she can.”
When it comes to care of the elderly, Bernhauser says: “I’m being controversial in saying it, but it isn’t seen as ‘sexy’. Yet I have known students who later went into the care of the elderly because they saw it as an area in which they could really make a difference and improve the quality of a person’s life. It is one of the most complex areas of health care, as patients usually have multiple needs, often including forgetfulness or dementia.”
She says that learning on wards under supervision of qualified nurses can sometimes be affected by the fact that the qualified nurse is also doing their own job. “In the training of doctors, money is given to the hospital trust to pay doctors to teach students rather than, say, taking a clinic. There’s no such funding for nurses who teach students in direct care of patients.
“I wouldn’t want nurses to supervise students for money, but the money could go into staffing the ward to allow for teaching to happen properly. I suspect that in many of the case studies highlighted staff had simply not had time to think about what they’re doing and were rushing to get the job done. I don’t offer this as an excuse, though.”
Ms Bernhauser believes that one of the most crucial elements in quality care on any hospital ward is the tone set by an excellent ward sister. “If she’s on top of things you can see it, and staff below her are also very good because she sets the standards high. There are more good ones than bad ones, but there are a few who get out of bed in the morning feeling it’s all right to be mediocre rather than excellent. That’s why we need to be very careful in how we select them.”
Before her death last year, the late Claire Rayner – a scourge to some healthcare workers, and welcome critical friend to others – agreed to co-fund a £20,000 a year endowment of a PhD placement at Huddersfield University dedicated to the study of some element of compassion in care. The first doctoral student, a very experienced nurse in elderly care, will soon start her study. As she did in life, Claire is still fighting for the vulnerable.