Care and compassion in the NHS

The Health Service Ombudsman's report on ten investigations into NHS care of older people has provoked an understandable, but wearingly familiar, wave of shock and media outrage.

The Ombudsman is not known for emotive language, but she says her 'harrowing' findings, reveal 'an attitude which fails to recognise the humanity and individuality of the people concerned and to respond to them with sensitivity, compassion and professionalism'.

If the language in the report is new, the findings are not. We know that poor care occurs in health care systems everywhere. The fact that all too often it is older people who suffer may reflect wider societal values, but from our work we know that it can happen to anyone. The fundamental problem is that the quality of health care is not reliable: the more vulnerable the patient, the greater the risk.

The media always focuses on 'what has gone wrong in nursing?' but the Ombudsman's stories are not just about nurses: they feature a wide variety of medical, nursing and support staff, in hospitals and in general practice, and many are about lack of continuity and coordination between hospitals and primary care.

The report is a clarion call to think much more deeply about how and why vulnerable people suffer at the hands of the people there to look after them. The failings in the Ombudsman's report point to something more than callous attitudes on the part of a few 'bad apples'. The stories are about personal and institutional failure. Reliable quality cannot be achieved by single individuals acting alone. If we have learned anything in the past decade about providing safe, high-quality care, it's that it requires sustained, continuous effort and focus over a period of years: it cannot be fixed overnight.

So what kind of practical actions could prevent the harm occurring in the first place?

First, we should stop thinking and acting as if 'patient-centred care' and 'patient experience' are different from clinical quality and patient safety. The cases illustrate perfectly that it is nonsense to do so. The care these patients received was unsafe (falls and bruises), clinically ineffective (failures to diagnose, poor prescribing, lack of pain relief) and neglectful.

At senior level, board and executive team members should be out and about, talking to patients, visitors and staff and seeing for themselves what goes on in wards, waiting areas and clinics. In the best organisations, senior leaders demonstrate by word and deed that quality of care is non-negotiable, and take an active interest in what is required to deliver it.

Staff don't need more blame and condemnation; they need active, sustained supervision and support. In the high-volume, high-pressure, complex environment of modern health care it is very difficult to remain sensitive and caring towards every single patient all of the time. We ask ourselves how it is possible that anyone, let alone a nurse, could ignore a dying man's request for water? What we should also ask is whether it is humanly possible for anyone to look after very sick, very frail, possibly incontinent, possibly confused patients without excellent induction, training, supervision and support. 

We need to develop much more systematic approaches to supporting staff who are delivering care, helping them to re-connect with patients and avoid 'case-hardening'. On our Point of Care programme we are currently working with one such practical method called 'intentional rounding' in a number of wards and hospitals. Instead of waiting for patients to buzz for help, with intentional rounding nurses take the initiative and visit the patients' bedside every hour to do whatever the patient needs and see if s/he is alright.

The regular anticipatory 'rounds' at the bedside reassure patients they have not been forgotten and, tellingly, result in an overall reduction in patients' demands. More importantly, by being 'patient-focused' rather than task oriented, staff can find themselves re-awakened to the needs of their patients as people. Rather than increasing workload as they had feared, the intentional rounds have encouraged productive relationships between families and carers and improved communications, leaving staff feeling more positive about the care they are able to offer.

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#346 Robert Munro

The Ombudsman's report investigated 226 complaints and reported on just 10. To use this as evidence of widespread neglect of older people within the NHS is unjustified. Many people mention anecdotal evidence of neglect but just as many give examples of excellent care. We need a proper investigation into this before drawing any conclusions. The DH Information Centre cannot even provide a figure for the number of complaints received concerning the care of patients aged over 65

#347 benny goodman
University of Plymouth

Agree. Poor care and behaviour happen in a context where the unacceptable becomes the norm. Kath Melia many years ago described the occupational socilaisation of student nurses and as a sociologist I argue that the power of socialisation to contextualise poor practice as acceptable is all too easy to understand given the complex pressured nature of many care environments. This is not to let individuals off the hook however but it is to recognise how context shapes decisions. Your idea of 'intentional rounding' is exactly what I was discussing with colleagues here in response to the question on what University nurse lecturers can do. it is certainly well worth a try.

#352 Red Dolphin
Red Dolphin

Ten cases, whilst each and every one deplorable, is not a sign of institutional failure in an organisation that employs 1.3m people. These are the 'bad apples' and the full weight of professional and federal law should be brought to bear on any involved in such neglect but it is the tiny minority. To tar the whole of the NHS with this brush is sensationalism.

That is not to say that standards have not slipped over the last 20 years with more emphasis on the pseudo-intellectualisation of nursing and the continued attempts to demean medicine from a profession to a job of work. "Intentional rounding' (am I the only one who weeps in despair when he hears such meaningless patter?) used to be called 'nursing'. The very fact that a programme exists to encourage nurses to visit patients before they buzz for help is an indictment of their current training, not to say attitude.

Bad apples aside, most mistakes and cases of poor practice in the NHS are due to either laziness or the failure to carry out usually simple instructions. This in turn is a function of the deprofessionalisation of medicine and nursing caused by a loss of the values of the past in favour of the shallow ideals of today. To change this around requires a wholesale change in the education of student doctors and nurses from ground level up and a strong, respected leadership for them to aspire to. This cannot happen overnight an certainly requires more than an effete soundbite of a programme that amounts to an apologist for the lack of basic principles.

#354 Anon

'Intentional rounding', 'anticipatory rounds' - whatever jargon is used shouldn't healthcare professionals such as nurses be checking on their patients regularly anyway?

This is hardly a model - rather common sense!

#357 Annie Laverty
Director Of Patient Experience
Northumbria Healthcare.

Most contemporary experts view patient safety and quality within a systems perspective, and yet whenever a public report details our failure to meet even the most basic standards of care, it seems our quick and convenient response is to ask nurses and nursing to shoulder much of the responsibility. It’s disappointing to see how pervasive this shame and blame mentality is.

Taking the time to understand the complexity of the work environment and engaging in strategies to reliably improve its effects, is paramount to high-quality, safer and compassionate care. Blaming is not only ineffective; it also focuses our attention on the last and perhaps least remedial link in the chain – the provider (Reason 1994.)

Highly reliable organisations will already have learnt the importance of capable & committed leadership, institutionalising a culture of safety and respect, providing patient centred care, prioritising multidisciplinary teamwork & communication and protecting an environment that supports the effectiveness and wellbeing of all staff.

#370 Annette Bartley
Quality Improvement Fellow
Health Foundation/ IHI

I am a nurse with over 30 years experience in healthcare and during this time there has been many reports about the declining standards of patient care. Whilst the Ombudsman’s report described in this blog relates to 10 incidents I think it’s time for healthcare practitioners to take a step back and reflect honestly about the current reality in practice. Whilst there are still encouragingly many shining examples of good practice, not a day goes by without a story in the press regarding a patients poor experience of care, the mid Staffordshire report reflected this reality . Many of us have experienced this firsthand or via the shared experiences of relatives and friends So a balance needs to struck in order to reduce this variation in practice and to ensure basic care needs are met for all patients 24/7.
My role is on quality improvement in healthcareand affords me the privilege of working closely with many frontline staff of all disciplines across the UK trying their to best to improve patient care and outcomes. They clearly recognize there is a problem with fundamentals of care and proactively seek solutions. The stringent cutbacks, and increased pressures placed upon staff to meet cost /quality targets, the increased dependency and higher acuity of patients cannot fail but impact on workload and subsequently direct patient care. Frontline staff see this firsthand and many acknowledge it and want to do something about it. However have difficulty finding time to jump off the treadmill in order to find time to reflect and to find a better way. They greatly value simple tools and methods whatever title is attributed to them, which help them to think critically about how they might better structure and organize care, and make better use of their time and resources
We need to somehow eradicate this constant cynicism about frontline care, stop arguing about the latest fads/tools and their titles and actually accept there is work to do to help busy frontline practitioners cope with all the pressures they are facing in order to deliver high quality, safe and efficient care focused on patients and their specif needs.
Evidence suggests that regular and well structured ‘rounding’ delivers both a significantly improved experience of care for patients, a reduction in adverse events such as falls, pressure ulcers and happier staff. Why would we not consider this? As long as we think critically about how we execute this process and ensure patient individual needs continue to be addressed it provides a more robust framework for safer, higher quality efficent care.

#617 Estelle Downing
Scheme Manager Sheltered Housing
Sussex Housing and Care

Compassion cannot be offered to 'clients' in the absence of a culture of compassion within the structures of the organisation. By this I mean an active cultivation of self-compassion in all working there and a compassionate approach between them, regardless of rank and skill level. Jargon is worthless in this context - it evades the issue of the absenc of love. The capacity for empathy lies within all of us - it needs to be woken up, activated. This should be the foundation of all work associated with the care of the vulnerable. From personal experience I can attest to the way work and life in general is enriched once this window has been opened. Imagine the futility of effort that brings a meal from its point of origin to be placed a few inches too far away for a vulnerable person's reach, and then removed, untouched later. But for a few inches of compassion ... a tiny additional push by a tired, overworked person and nourishment would not have been neglected. The same tired overworked person, if given appreciation, acknowledgement and compassion, would likely find the energy and the empathy necessary to go all the way ...

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