Thursday 30 March 2017

The NHS: A Happy and Safe Place to Work?

For most of my working life I’ve worked for the NHS, for different organisations and different Trusts, in a lot of different jobs. My very first job, even I trained as a nurse, was working for the NHS, it was back in 1984 and it was entering data into a computer, in an old prefab building in the grounds of a Liverpool suburban hospital.

I have seen many changes in the NHS over the years, many Governments have “reformed” it, and there have been many changes to its structure, and many of these changes have not been for the best. The one thing that has always been a constant is the staff. The NHS is the biggest employer in the country, and is the fifth biggest employer in the world (1), its staff are its biggest resource. An empty hospital never made anyone well, it’s the staff that work there that do.

So what is it like to work for this huge institution?

Since 2003 the NHS has run its Staff Survey (2). This yearly survey asks NHS staff about their experiences
of working for the organisation. Since 2010 the NHS and its staff has been under enormous stress and pressure, budgets have been cut, there are staff shortages, pay has been frozen and yet demand on the NHS keeps increasing. Last winter, a mild winter, saw the NHS plunged into another “winter crisis”, now almost a yearly event. Therefore we would expect the NHS Staff Survey would be full of negativity and staff stress being vented, but it’s the opposite.

The latest Staff Survey (3) paints a picture of staff who enjoy their work and value working for the NHS. 75% see the NHS’s priority as patient care and 75% are enthusiastic about their jobs (4); 59% of staff said they always look forward to going to work and 60% would recommend the organisation they work for as a good place to work (4). Staff still value the NHS and enjoy their work. Sir Robert Frances (the QC who chaired the enquiry into the Mid Staffordshire scandal) said that the NHS was only being held together by the “superhuman efforts” of its staff (5).

So the NHS is a great place to work in for everyone. Well yes and no. Unfortunately, it is not the same for everyone.

Black and ethnic minority staff (BME) are much more likely to be bullied and harassed by white colleagues and managers, the first national review by NHS England (6) found. It found one trust were BME staff experienced twice as much harassment from colleagues than white staff, and in over 80% for Trusts BME staff faced far higher levels of discrimination from managers than their white colleagues.  Yet levels of harassment from relatives and the public were the same for BME staff and non-BME staff (6).

In 2014 a damning report was published into the state of BME staff in the NHS, called The Snowy White Peaks of the NHS (7), a title that is more than ironic. Its findings are very uncomfortable. In all the NHS Trusts serving London, the most racially mixed city in the country, the vast majority of leaders were white. This was repeated at national level, with key NHS organisations and healthcare regulators having very few BME staff in top leadership roles. Only 3% of Directors of Nursing being BME nurses, a figure that had not changed in ten years. The number of BME nurse managers fell from 8.7% in 2007 down to 7.8% in 2012, with few BME nurses at Band 7 and 8 (7); 14% of the population of England and Wales is non-white (8).

This report maybe three years old but we just have to think about our own Trusts, how many of the senior managers are non-white. In the Trust I work the senior management is very white experience.

But it isn’t just racism that NHS staff face, the organisation is not free from homophobia either.

In 2015 Stonewall (the LGBT campaigning organisation) published Unhealthy Attitudes (9), their report
into the treatment of LGBT health and social care staff; and it was shocking reading. It found that one in four people (25%) had heard a colleague make negative or homophobic statements about LGBT people, and one in five (20%) had hear negative statements about trans people. A quarter (25%) of them had been the victims of homophobic bullying from patients and service users, and 10% had heard colleagues make claims that LGBT people can be “cured”.

These statists may sound cold but the report also carried the realities behind them, it was full of personal quotes. The nurse who was told he should be hung for being gay, by another nurse. A nurse's manager told her that homophobic comments were “only banter”. A nurse who was ostracised by his whole staff team, at work and socially, when it came out he's gay. And many comments were trans people are called “it” or “she-male”.   Then there were the NHS staff who almost wore their homophobia as a badge of pride. A Healthcare Assistant who said people are not born LGBT but “choose” this “lifestyle”. A doctor referring to anyone he doesn't consider “normal” as “deviants” whose needs shouldn't be “forced” on the majority.

This year’s Stonewall Top 100 Employers list (The top 100 employers who have worked to be inclusive and to be a safe place for LGBT people to work) is out (10), and only seven of them were Health and Social Care organisations. None of the top ten organisations were an NHS ones, and only one of the top fifty was an NHS organisation, St Andrews Healthcare at number 43. None of the big NHS Trusts or any of the famous ones even made it onto the list. This speaks volumes about how seriously NHS organisations take LGBT inclusivity.

How has the NHS got into this situation? Unfortunately, it reflects the wider society we live in, with all its prejudices and discriminations. We still do not value difference in people. NHS senior management is still dominated by white heterosexual people, and too often they promote people like themselves. We still often only pay lip-service to diversity, seeing as a tick box on the mandatory training list. My own diversity training this year was an online presentation, that took 15 minutes and it covered all “minorities”.

We need a culture that values all NHS staff, and values the differences people can bring to their roles. LGBT and BME people are part of our society that the NHS serves. If the NHS does not value and encourage its own LGBT and BME staff then how can we say we can offer non-discriminatory care to LGBT and BME patients?

The NHS is a far more positive place to work then it was in 1984 (When I first worked for it) but it still has far to go, though on the other hand there are worse employers to work for.

Drew Payne

Friday 24 March 2017

Just Another Occupational Hazard?

The RCN surveyed 1,300 community nurses (1) and their results weren’t comfortable reading for me, a community nurse myself.

A half of those community nurses surveyed had been the victim of abuse at work, and one in nine had been physically and verbally attacked. Yet only 13% of them have personal alarms (even though they were widely available in 2009 for lone workers and originally government funded).

Cost-cutting measures are putting community nurses’ safety at risk but it goes further than the lack of personal alarms, it is the increased pressures being put on community services without extra resources. 

Hospitals have to treat more patients for less money (The yearly increase to NHS funding being only 0.9% [2], well below even inflation), so they are discharging patients earlier and earlier, and more and more ill patients are being treated in the community, but there hasn’t been the extra resources put into the community to meet this increasing demand.

Community health services have around 100 million patient contacts each year, and account for about £10 billion of the NHS budget (or 8.3% of all NHS spending) (3). There has been a 15% increase in District Nursing workload between 2011 and 2015 (4) yet the NHS only plans to increase spending on Primary Care as a whole between 4% and 5.5% year-on-year for the next five years (5). There has already been a 15% increase in the workload and it shows no sign of decreasing, this planned increase in spending will be far outstripped by demand. This does not take into account the £2.5 billion cut in Social Care funding, 20% of their funding (6); which also has a severe knock-on effect on District Nurse caseloads.

There has also been a huge fall in the numbers of District Nurses and Community Nurses. Since 2009 there has been a 28% fall in District Nurses numbers and the Community Nurse workforce has shrunk by 8% to 36,600 (4). This alone puts a huge strain on the service.

Patients’ expectations of what can be provided in the community are often unrealistic, measuring it against the very public targets of A&E Departments, and expecting instant access to services. More people want medical input for things that they can manage themselves (“It’s a nurses’ job to give my granny her tablets. The nurses did it in hospital”). The community isn’t an acute service and many patients are reacting with anger and frustration when they are faced with its limitations.

Also, patients in the community are often not aware of shortages of Community Nurses. Sometimes the only time they are aware of it is when they have a visit cancelled. Patients on hospital wards can see how many or how few nurses are on duty and how busy they are. Patients in the community only see a Community Nurse when they visit that patient’s home, they cannot easily see how few nurses are available and how busy they are. Patients are isolated away from the stresses that many Community Nurses are under.

More and more working practices are also putting community nurses at risk, nurses working on their own on late shifts until ten o’clock at night, twilight and night time community nurses working on their own, community nurses working in uniform, poor or unrealistic Lone Worker Politics, staff working without easy access to senior nurse support, working with unrealistically large caseloads and lack of time to do full risk assessments.

Often senior manager’s poor handling of abusive patients makes the situation worse. Senior managers who are reluctant/afraid to confront abusive patients, managers’ fear of generating complaints (“Don’t upset Mrs. ____, because she’s only put in another complaint”), also the pressure to meet targets and numbers of patients treated.

The NHS has always been poor with dealing with abusive patients, but worst so in the community because the argument always comes back, “They’re housebound, who else will see them if community nurses won’t.” A friend of mine, another community nurse, was punched by a patient at work. The same patient had slapped another nurse and been racially abusive to other nurses. Senior management wouldn’t remove treatment from this patient, still requiring nurses to see her. They were only spared further abuse when the patient went into hospital.

NHS Improvement has produced “Safe, sustainable and productive staffing in district nursing services” (7). These draft guidelines are designed to identify “the organisational, managerial and contextual factors that support safe staffing” in the community. But these guidelines do not make any recommendations as to what are safe staffing levels or safe caseloads numbers, instead recommending that that these numbers be agreed “locally”. This fudge could easily lead to poor staffing levels being accepted as the norm, and asks the question what is the point of these guidelines?

Cuts have put community nurses safety at risk but it goes deeper than just lack of personal alarms. We know of the problems caused by under staffing on hospitals wards, no one in the NHS can forget the Mid Staffs scandal (8), why aren’t we more concerned about the same problems in the community?

Drew Payne

Friday 17 March 2017

Is Failure Ever An Option?

Week on week the media is full of stories about failings in the NHS. Two patients died while waiting in a corridor for treatment, (1), a woman died from a brain haemorrhage after there were no intensive care beds available (2), a woman died after surgeons inserted a heart valve upside down (3), surgeons operated on the wrong body part of a patient (4), an NG tube being inserted in a patient’s lungs instead of the stomach (5), and at an A&E Department a patient lay dead for four-and-a-half hours before being found (6).

Previously anyone of these stories would have caused public outcry and would certainly had the nursing profession up in arms and condemning these failures in care, but now these stories barely reach the front pages of newspapers and news websites. Are we no longer shocked by failure?

The NHS is under immense strain, our workload has vastly increased; patients attending A&E Departments has increased by 6% in the last year (7), 193,000 patients a month are waiting beyond the target of 18 weeks for surgery (8), there has been a 3% in emergency admissions via A&E (7), diagnostic tests have increased 5.8%, and consultant-led treatments have increased 5.1% (9). And all this extra demand is having an affect on NHS services. Cancer treatment targets have been missed for the last three years (10), in December and January only 82.3% patients attending A&E were seen within hours (The target being 95%) and in the same time 18,000 patients waited on trolleys of four hours or more to be admitted into a hospital bed (11).

Yet as this demand increases NHS resources decrease, in real terms. The NHS receives an extra 0.9 funding a year (12), and this has been the case since 2010. The inflation rate, December 2016 to January 2017, was 1.6% (13). This doesn’t take into account the extra costs forced on the NHS. Delays in discharging medically fit patients because of no adequate social care (so called “Bed Blockers”) are costing the NHS £900 million a year (14); many drugs have increased in price far more than inflation, prices for generic cancer drugs have risen sharply in the past five years, Tamoxifen and Bulsufan are now 10 times more expensive even though they are no longer under patent (15); the winter crisis we have all lived through has cost the NHS an extra £900 million (16).

But with this increased demand there has not been an increase in staff to meet it, actually the opposite is true. In 2010 there were 8,153 vacant nursing posts in the NHS, 2.5% of the nursing workforce (17), last year (2016) there 21,205 vacant nursing posts, 10% of NHS nursing posts (18). That is a four-fold increase in the number of nurses the NHS is short of, and that is just nurses. It is similar with all NHS healthcare professionals.

There’s more work to do, less resources to meet it and less of us to do the work. It is the perfect storm for things to go wrong. Under this stress mistakes happen, things are forgotten, there isn’t enough time to do everything. But this is healthcare and there is no room for errors or mistakes. If an employee makes a mistake at Tescos the worst that happens is costumers can’t buy their favour sliced bread. If an NHS nurse makes a mistake than a patient’s life could be seriously impaired or even ended.

So why aren’t we more shocked when things go wrong, when patients are harmed or even die? Is it happening so often that we have become numb to it? Are we relieved to hear that it didn’t happen were we work? Are we too busy and stressed to notice?

But the leadership, at the very top of the NHS, seems completely out of touch with what is
really happening in the NHS, the leadership of Jeremy Hunt. In November 2016 Jeremy Hunt issued a statement saying “NHS [has] extra resources to make sure it is better prepared than ever before” (19). At the same time he described calls for extra NHS funding as “misjudgement” (20), ignoring the record deficit in funding the NHS is facing. In January, as the winter crisis was deeply hitting patient care, Jeremy Hunt hinted that the four hour A&E target could be relaxed (21). Shifting the targets to reduce bad news? When the British Red Cross called the NHS winter crisis as a “humanitarian crisis” (22) Jeremy Hunt was nowhere to be found to reply to this (23), over a whole weekend he didn’t issue any statement, he didn’t seem to be working at the weekend. When he finally issued a statement he said that there was “no excuse” for the winter crisis (24), ignoring all the factors causing it. His tone was very much to blame hospitals, and therefore their staff, for the applauding situation. Now in March, the day after the budget which announced extra funding for social care but none for the NHS, Hunt demanded that all NHS A&E Departments must hit their four hour treatment target (25). No extra funding or resources to do this, just Jeremy Hunt demanding it.

How can anyone respect such poor and arrogant leadership?

Jeremy Hunt does not seem bothered by these increasing failings in the NHS, his silence on the subject (Except for the occasional apology when he is embarrassed by the media) certainly says that failure is acceptable to him.

Poor healthcare ruins lives and we should never accept this. We should be shouting from the hill tops, in the streets, in anywhere were people will listen to us that one death because of an NHS failure is NEVER acceptable. Why aren’t we? Or have we grown so tired of this government’s complete lack of concern about the state of the NHS?

With all the pressures, rising demand and cuts to its resources the NHS is under, has failure lost its power to shock? It feels like it…

Drew Payne

Thursday 9 March 2017

And The Truth About Stress

This winter has been very hard on the NHS; nearly a quarter of patients in A&E waited over four hours (1), far less than the 95% target of patients being seen within that time; there were more than 18,000 "trolley waits" (1), patients kept in corridors and on trolleys as they wait for a bed to become available; over 190,000 patients a month waited more than 18 weeks for their surgery (2); at one point 40% of hospitals issued alerts over bed capacity, which happened during the first week in January (3); it has all added £900m to the NHS deficit (4), and this all lead to the British Red Cross calling NHS a “humanitarian crisis” (5).

There has been a lot in the press and on our media about the effects all this has had on patients, there have been many stories of people’s grandparents lying on trolleys for hours on end, but there have been no stories about the stress this crisis has put NHS staff under. Working at this level is physically and emotionally draining, it well certainly take its toll from people. This is busy and stressful work day in and day out, no one day when the pressure eases up (No “slow Tuesdays”), no chance for staff to have an easier day. I have worked in situations like this and I know the physical and mental pressure this puts you under.

Sir Robert Francis QC, who chaired the infamous inquiry into Mid Staffordshire NHS Trust, said that the NHS was only being held together by the “superhuman efforts” of its staff (6). He is right, the extra effort staff have made at work, working above and beyond their required duties is what is holding the NHS together, which has preventing another Mid Staffordshire type scandal hitting the NHS. The RCN (Royal College of Nursing) has found evidence of nurses repeatedly working 12 hour shifts without a break or even without drinking enough water during their shifts (7).  But this situation cannot continue, staff cannot survive under this level of stress. As Sir Francis said: “It can’t carry on like that indefinitely without something going badly, or risking going badly wrong” (6).

How have staff been rewarded for this “superhuman effort”? With nothing!

NHS staff have faced a 1% pay freeze since 2010, as we are repeatedly told that it is patient care or our pay rise (Making it seem we are “selfish” for wanting a pay rise), and in reality our pay has been cut as inflation hits day-to-day prices. In this week’s budget there has been no extra funding for the NHS (8), so no pay rise for NHS staff. MPs received a 1.4 % pay rise last year (9), after they’d received an inflation busting rise of 10% in 2015 (10). This week’s budget did find an extra £2 billion for Social Care funding, but to be phased in over three years (8). This £2 billion has to be shared amongst 152 councils (11) and phased in over three years, this will not relieve the chronic under funding of social care by next winter.  This shortage of social care has caused 10% of NHS hospital beds to be filled by people medically fit to be discharge but who cannot be discharged because there isn’t the social care to support them at home, costing the NHS £900 million a year (12). Yet, at the announcement of this extra Social Care funding, Jeremy Hunt has demanded that all NHS A&E Departments MUST met the four hour target now (13). The Minister of Health, in the face of the “superhuman efforts” by NHS staff, has announced that we HAVE to work harder. Can anyone respect such an arrogant man?

This increased pressure has already had a severe impact on NHS nurses. Janet Davies, chief executive at the RCN, has said that conditions are worse than they have ever been in the NHS (14). Record numbers of nurses have applied for hardship grants just to make ends meet, the RCN also reported (15). The pay freeze forced on nurses is biting hard into nurses’ welfare. But many nurses are already voting with their feet and leaving the NHS. Last year 4,663 nurses requested verification certificates from the NMC (Nursing and Midwifery Council), the documents needed to work overseas as a nurse (16). Since 2011 26,028 nurses have request verification certificates (16). This is just nurses wanting to work overseas. The NHS has a record number of empty nursing posts. As of December 2016, there are 21,205 empty nursing posts in the NHS, 10% of the nursing workforce (17). Between 2013 and 2015, there has been a 50% increase in nursing vacancies (18). There seems no end to this shortage of staff, and all the stress it creates for NHS nurses. Universities have seen a 23% fall in the number of people applying to do nurse training since the Government removed bursaries for student nurses (19). Leading nursing academics have warmed that Brexit could also severely affect nursing numbers (20). There are 33,000 EU nurses working in the NHS (20), if they leave after Brexit (Whether voluntarily due to fears of job security or forced to leave due to post Brexit immigration legalisation) then the NHS will be in a severe crisis.

Whenever Jeremy Hunt has been challenged over the shortage of NHS nurses he has replied with the claim that he has “put” an extra 3,000 nurses on hospital wards (21). Yet 93% of NHS Trusts reported shortages of registered nurses and 78 per cent reported hard-to-fill nursing

vacancies (jobs vacant for three months and longer) (17). How does this equate with Hunt’s claim? Is this just another example of how little he understands about the real situation in the NHS?

I work as a Community Nurse, in a District Nurse team, and our team is made up of approximately 50% agency nurses. This week I have regularly one of only two regular staff on duty (The rest being agency nurses). Since 2012 our workload has over doubled but the number of regular nurses in our team has reduced. These stresses and staff shortages are right across the NHS. I have been a nurse for over 25 years and I cannot remember a time when stress levels were so high and moral was so low in the NHS.

The NHS’s staff are its biggest and most valuable resource, a resource that it should be valuing and caring for. Yet, the Government’s actions this week (The Budget [8] and Jeremy Hunt’s post Budget statement [13]) show how little they are concerned about the crisis affecting the NHS and over stressed NHS staff. On Sunday (5/3/17) 250,000 thousand people marched through London in support of the NHS and against the proposed £20 billion in cuts by 2020 (22). Why didn’t Theresa May, Philip Hammond and Jeremy Hunt listen to them? Is it that they just don’t care about the NHS?

Drew Payne