Nursing levels to be written on ward wall at Salford Royal Hospital – Manchester Evening News

“A hospital is to put up signs on each ward telling patients the number of nurses on duty – so they can see when they are understaffed.

Each ward at Salford Royal will soon have a whiteboard telling patients and relatives the number of nurses and healthcare assistants who should be on duty – and how many there actually are at work.

Due to be rolled out in coming weeks across the hospital, it aims to give greater openness on how the hospital is doing to make sure wards are properly staffed.

It is believed to be the first hospital in the country to make staffing levels for each ward public – and bosses believe others may follow suit.”

via Nursing levels to be written on ward wall at Salford Royal Hospital – Manchester Evening News.

– The transparency is to be applauded. When I was last an in-patient, in 2012, nurses confided that they were under orders not to tell us when the shift was under-staffed. “But we can see that for ourselves!” replied one sensible old gaffer as the only nurse on duty rushed about doing the meds single-handed one morning.

But what are the consequences for patients of seeing this written on the wall? How would you feel if you saw ‘Safe level of nursing – 3; Actual level of nursing – 1’?

Don’t know about you, but I’d be inclined to panic, consider the option of simply fleeing, after which I would make an almighty fuss demanding to see Matron, the Chief of Nursing Staff, the Chief Executive, Chairman of the Trust Board, and anyone got the number of the local paper?

Maybe that’s the idea. Get patient riled enough to demand the shortage be fixed whatsoever the cause? If that is the purpose then they had better be ready for the consequences.

Addendum: Assuming they have thought this through, the board should also say “If you are concerned about current nursing levels this is who you should speak to…[Sister/Matron/PALS etc].” Otherwise you just leave people hanging, with information but not knowing what to do with it. Have asked Salford to comment.


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As The NHS Crow Flies…

“Southend Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex.”

via Urgent care services – NHS Choices.

…not that I would – as there are closer options – but if decided to haul my carcass down to good old Southend Hospital for a viewing, NHS Choices handily can provide me with the distance between my billet and the hospital: fifteen and half miles give or take. Very useful.

But then it also informs me, in parentheses, that the distance quoted is “in a straight line”. Hang on a minute, any crow flying from here to there would not only have to find its way across the emptiness that is the Dengie Peninsula, it would, first, have to make it over the Blackwater River and later the River Crouch, before over-topping the suburban fastnesses of Rochford and environs then finally swooping down on its prey. As it were.

Fine if you are that crow – though if you were a wounded crow in need of hospital treatment for a broken wing say, perhaps not so fine after all. Utterly meaningless in any case to the human, land-fast, traveller.

Google Maps more usefully gives the real door-to-door distance as over 31 miles; twice the nominal NHS Crow Road.

I  am all for the NHS giving information to its patients and the wider public about how and where to access its services (though to be honest anyone who doesn’t know where their local hospital is or how to get there is perhaps not worth saving), but when the information is systemically duff – i.e. it has duffness built into it – you have to ask: 1) Who thought this was a good idea; 2) Who decided to waste public money on such a non-runner? Or flier.

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“Elderly patients will get personal NHS worker to coordinate health care, pledges Jeremy Hunt.” Brilliant idea Jeremy! Not.

“Nobody disagrees with the concept of a case manager,” [Jeremy Hunt] said.

via Elderly patients will get personal NHS worker to coordinate health care, pledges Jeremy Hunt – UK Politics – UK – The Independent.

…don’t they? You sure about that?

For starters, the scheme is dead in the water unless the scope is widened to include social care agencies, whether statutory, voluntary or third sector. That care of the elderly, in particular, requires the co-ordinated efforts and inputs of health and social care is at least and at last accepted in theory, if all too often lacking – or indeed absent – in practice. Even up to the mid-Nineties you could meet a Social Services commissioner who would ask: “What’s Chronic Disease Management [as it was then known] to me; what am I to CDM? That’s changing leg dressings, that’s a matter for the District Nurses.” Similarly, health professionals would be resistant to receiving progress reports or alerts from Home Care workers who were not medically qualified.

If the Great Leap Forward of the ‘Single Assessment Process’ [NHS Plan 2001 – remember that or it?] achieved anything other than massive organisational disruption to deliver the blindingly obvious – talk to each other professionals! – it was in opening eyes to the mutually necessary contributions health and social care each made, not only to individual older people but also to respective organisations and systems; and their all-important purses. Road to Damascus moments did indeed occur as silo inhabitants suddenly got it that they hung together or were hanged apart.

So if this next GLF – this plucked from the manual of integrated care rather – notion is to be of any use whatsoever it cannot only be a matter for the NHS alone. But then, having accepted that, does the task become any easier; is it still incontrovertible that a ‘case manager’ is the thing to do – the big thing that will 1) work, 2) deliver what’s needed? It isn’t.

A ‘manager’ implies someone with authority to act and, where necessary, to instruct. A ‘case manager’, therefore, requires not only a skills set that may well be absent in a worker with specific but limited operational skills, but also an agreed role and function to command and control if needed.

A Community Nurse may well aspire to a hospital based re-enablement team completing their work before a consultant decides the older person recovering from a double lower limb amputation is medically fit for discharge home; a Social Worker may equally hope that the social housing agency has completed the necessary adaptations to that person’s home before they arrive, and that the GP has arranged for Community Nurse attendance, or that the Home Care agency has the capacity to provide a three times a day double-handed crew with specialist knowledge in the use of hoists and tracking. But neither can insist on it. Open communication between agencies, careful and negotiated planning between individuals, are both needed; but you simply cannot just put one person in charge and say “You’re the Case Manager. Get it sorted.” That way madness and a stampede for the door both lie.

Where there is an established pattern of services for an older person with a chronic, progressive disease or illness – for example, in dementia care – there may well be an existing and integrated team of health and social care professionals (a Dementia Resource Centre) who are the natural, go-to hub of both activity and oversight. Regular monitoring occurs and reviews can be held to assess the stability or otherwise of the placement, with agencies able jointly to consider adjusting or re-aligning their inputs in order to avert any potential or impending crises; though even here front-line workers are unlikely to empowered and authorised to agree changes without reference to line-managers.

But there are also many circumstances in which an older person, as any other, may need to travel down a health path with discrete, time-limited interventions. A suspected cancer diagnosis, for example, requires a progression from primary to secondary health services (general then specialist maybe), through perhaps surgical teams and on to other oncologists, rehab workers – physiotherapists, S&L therapists – counsellors, support groups, then on to social care agencies and back to primary care for pain management and review. Who within all of that is ideally – or even usefully – placed to be the ‘Case Manager’. The initially referring GP? The diagnostic or treatment specialists? The rehab workforce? No one but the GP will have been there from the onset, so unless they take on every case – yeah right! – there would need to be lead hand-overs to other disciplines over time, as and when they come to the fore.

But hang on a moment! Isn’t there one other person who is present throughout this or any other progress through the complex, inter-related yet not often speaking to each other, systems that comprise comprehensive care of the elderly? Why of course! It’s the older person themselves! Now there’s a scary novelty – put each person in charge of their own case; give them the authority to communicate and co-ordinate, to command and control.

You’ll never see that happen of course. The NHS would have an attack of the vapours, Social Services would faint clean away. But that’s what you would do isn’t it, if you could and if you had to? Would you leave it to ‘them’ to do it on your behalf? You would the one, and you wouldn’t the other.

Tell that to Jeremy Hunt. Someone should before he wastes everyone’s time and money coming up with grand schemes – with ‘delivery teams’ who meet every second Monday for something to do, and evangelical ‘champions’ who are always desperate to make eye contact in corridors – that are badged ‘Case Management’ to keep the policy wonks happy and management quiet, but which deliver little good or – more likely – simply more muddle, mess and mayhem.

I won’t say ‘if Jeremy Hunt thinks something’s a good idea, it isn’t’; but it’s a decent working rule of thumb, and a temptation harder to resist by the day.

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‘Police ordered to slant crime data’ – Telegraph

‘The head of the Police Federation will suggest a “fear factor” in the wake of the Leveson Inquiry is preventing officers from blowing the whistle on how crime statistics are being manipulated.’

via Police ordered to slant crime data’ – Telegraph.

…and so these are the same police officer who would be required to investigate NHS managers if Jeremy Hunt’s latest wheeze to create a new criminal offence of manipulating figures on waiting times or death rates is enacted are they? What could possibly go wrong?

Quis custodiet ipsos custodes indeed.


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A&E chaos is the predictable result of GP contracts and EU interference – Telegraph Blogs

“But if a large proportion opt out of evening and weekend work and there are insufficient locums to cope with the demand, what then? The likelihood is that people who would otherwise be seen by a GP will instead flood the already over-stretched casualty departments at the local hospital….So how will the system cope if it has to deal with greater demand caused by the GP contract? More to the point, how will it cope when the Working Time Directive, the European law that limits the number of hours to be worked, hits the NHS?”If I could foresee this fiasco, presumably Health Department could too but chose not to do anything about despite the pleas of many professionals. In 2004, James Johnson, chairman of the BMA council, said: ‘‘We have been trying to alert the Department of Health to the scale of the impending disaster for at least three years.”

via A&E chaos is the predictable result of GP contracts and EU interference – Telegraph Blogs.

– Philip Johnston in the Telegraph today, quoting his own warning and that of James Johnson, the then chairman of the BMA Council, in 2004 about the stone obvious dire consequences of the Labour Government’s astonishing, insane offer to GPs that they could opt out of direct responsibility for out-of-hours primary care if they so chose.

The causes of the current A&E crisis are legion; the 2004 changes to GP contracts a significant but not sole reason. The lesson though that leaps off the page, then as it does now, is that if you attempt to change one facet of a complex system without being willing, at the very least, to attempt to predict the possible consequences of that discrete change on other parts of the system you are not merely inviting catastrophe you are sending it a map and its train ticket.

And so how does this shower respond – in a ‘whole systems’ way – to the approaching whirlwind? Jeremy Hunt announces he’s going to bung some money – that may not even exist – at A&E services in the vain hope that by painting the picket fence he can stop the tornado flattening the farmhouse.

Hunt also says it’s all the GPs fault anyway. So that’s all right then. Sadly, political point scoring when you should be undertaking comprehensive root-cause analysis fixes nothing. ‘Tis hard not to recall the Guardian [bias sample accepted] and the Museum Associations Journal [same bias] surveys that asked if Jeremy Hunt had been any good as the Culture Secretary: a resounding 100% ‘No’. As Health Secretary? Who could possibly say!

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Stroke survivors and their families left to deal with the emotional impact alone, says report – Health News – Health & Families – The Independent

“Of more than 2,700 people surveyed at the end of last year, 79 per cent claimed to have received no information or advice on how to cope with the emotional consequences of strokes.”

via Stroke survivors and their families left to deal with the emotional impact alone, says report – Health News – Health & Families – The Independent.

“The damage caused by a stroke can be widespread and long-lasting. Many people need to have a long period of rehabilitation before they can recover their former independence.

The process of rehabilitation will be specific to you, and will depend on your symptoms and their severity. A team of specialists are available to help, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors.

The damage that a stroke causes to your brain can impact on many aspects of your life and wellbeing, and depending on your individual circumstances, you may require a number of different treatment and rehabilitation methods. These are discussed in more detail below.”

– NHS Stroke Recovery online

A seeming massive disconnect between the NHS aspiration and intention and the reality of the ‘patient experience’. The NHS says it is aware of the enduring consequences of strokes and that it offers on-going treatment, help, support and advice. Patients, however, are reporting that they hear little or nothing from the NHS about what their needs are likely to be – physical, mental, psychological or emotional – and what the NHS can do, either directly or indirectly by referral to external agencies such as the Stroke Association. 

A question then – one to which no ready answer emerges – why is this so, what is causing the disconnect? Does the NHS, for example, see itself as the provider of initial medical treatments and first-phase rehabilitation/re-enablement, after which the burden and baton passes to Social Services [where eligible] or to the voluntary sector? Is there a failure of a person-centred ‘whole systems’ approach, replete with organisational boundaries, with restricted funding or ring-fenced budgets, or with professional fiefdoms that control who or what is in and who or what is out?

Assuming the validity of the disconnect it would be worth finding out the causes, not least because longer-term failures to deal with the consequences of strokes will, eventually, be more costly for the public purse: increased risks of further, catastrophic strokes; family breakdowns; financial consequences of not being able to work; carers having to give up jobs; stroke patients needing treatment for depression, etc.

In the absence of knowing the cause/s it would be facile to recommend action, beyond perhaps a mandatory one-year follow-up for all stroke admissions to hospital in order to learn from real patient experience what happens to people after discharge. What the Vanguard method would call the necessary first step of ‘Check’. Find out what’s really there, not what is planned, intended or believed to be the case.

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Wanda Maddocks: Jailed in secret – for trying to rescue her father from care home where she believed he would die | Mail Online

“Her family said Mr Maddocks, a retired painter and decorator from Stoke-on-Trent, had been held ‘like a prisoner’ on the orders of a local council.”

via Wanda Maddocks: Jailed in secret – for trying to rescue her father from care home where she believed he would die | Mail Online.

Although not specified in the article, it is reasonable to assume that the Local Authority had granted the care home a ‘Deprivation of Liberty’ order.

It is the Alice in Wonderland logic of the Mental Capacity Act 2005 – as amended by the Mental Health Act 2007, which brought in the ‘Deprivation of Liberty’ regulations – that the agency [in this case the Council] that commissions a provider [the care home] to meet the needs of the person, congruent with his rights of liberty as a citizen, is the same agency that will then – on application by provider – authorise that the person be deprived of their liberty because the care home does not believe it can meet the needs of that person without so depriving him of his rights to liberty as a citizen.

There is no independent agency that can look at the case objectively and then determine if the person can be lawfully deprived of his liberty, or whether the Council as commissioner or the care home as provider could and should meet the person’s needs without depriving of his liberty. There is no equivalent to the Mental Health Tribunal to which appeal can be made, as can happen if a person is being detained under the Mental Health Act. The Court of Protection only becomes involved if – as in this case – there are disputes about, or challenges to, the Deprivation of  Liberty order. It is – or should be – astonishing that in this country a person may be lawfully deprived of their liberty by administrative process only.

That one secret incarceration then led to another ought to be a matter of deepest concern and alarm. That all of this is entirely congruent with the statutory and regulatory powers of the Mental Capacity Act strongly argues that the law should be changed. From an instructive historical perspective it is worth remembering that the Mental Capacity Act 2005 was the Labour government’s response to the Bournewood case and judgement in 2004.  The European Court of Human Rights had determined that the nub of the problem was that HL’s de facto detention had not been  ‘in accordance with a procedure described by law’. Not that it was a bad thing in itself, not that the UK could or should do better, but that there had been no proper procedure that could be followed. This gave the green light to the Government not to find better ways of caring for people with complex mental capacity problems, but to invent the administrative process of ‘Deprivation of Liberty’. Cunning or what?

Why is there not the greatest public outrage and protest at the intent and the operation of the Deprivation of Liberty regulations? Because the people to whom they are applied, the people who are being detained in care homes and hospitals, are by and large older people with dementia. They have the least voice and they are perhaps society’s least concern. Some several years ago I visited a care home as part of a ‘due diligence’ process for its possible sale from public to private ownership. On the outside of every bedroom door in the ‘dementia wing’ was a bolt high up accessible only to staff. This was – the home freely admitted – in order to lock the residents in at night “to stop them wandering, or hurting themselves or going into other people’s bedrooms”. Of course, also a brilliant way of cutting night time staffing costs: one sleeping warder, not three waking care workers. Ten years ago that was as unlawful as it was disgusting. Under the Mental Capacity Act it remains disgusting, but it may now be lawful. All it takes is the penny-pinching care home to ask the cash-strapped Council if they think it’s OK and for the Council to say “It’s not ideal, but it is cheap, so carry on.”



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