Making My Vote Count, part 4

As I keep saying, a week is certainly a long time in politics, and it is a long time with this blog as I try and engage with my local candidates. It seems I am getting closer to actually engaging with them, accept it is now only six days to the election.

Last weekend The Green Party candidate finally put up his email address on the Who Can I Vote For website, the last of my local candidates to do so. It does seem very last minute, with a little over a week to the General Election. Of course I emailed him my questions (1), how quickly he’ll reply to me I just don’t know.

Monday I came home from work and found another campaign leaflet from the Liberal Democrat candidate. This leaflet was very high on promises about Brexit and supporting local residents, though it is very low on measurable policies. He lists five reasons to vote for him, none of them are about the NHS. The front of his leaflet does say, “More money for NHS hospital, reducing waiting times.” What he does not say is how much more money he will give and by how much he would reduce waiting times. It could be as little as £1 more money and reduce waiting times by 1 minute. This statement is so vague, it is unmeasurable.

Thursday I received my first reply to my email. The UKIP candidate sent me an email and she actually answered some of my questions. Her points were:

• UKIP will end PFI (Private Finance Initiatives) financing of hospitals and cancel current PFI contacts.
•  They will raise the tax allowance to £13,000, before any tax is paid, and they will raise the point at which the top rate of tax to £55,000.
• They will give an extra £9 billion a year, until 2021/22, in funding to the NHS and an extra £2 billion to social care funding.
• They will increase the number of nurses trained, fund nurses returning to work, and end the 1% wage cap on nurses.
• They will train more emergency medicine consultants.
• And UKIP will “establish a Royal Commission to find a way forward that allows the NHS to hold fast to its values while meeting the challenges of the future”.

Now these claims sound very reasonable, on the surface, but a look deeper at them finds there’s not a lot of substance to them.

PFI is a big finance burden on the NHS. The private businesses, financing the original deals, are owed over £209 billion over the next 35 years (2). The money paid to them, in 2015 alone, equalled 0.5% of Britain’s Gross Domestic. These deals are draining money from the NHS but ending them is going to be very difficult and expensive, an expense that the NHS might not be able to meet at once.

Increasing the tax allowance will help a lot of people, nurses included. Raising the top level of tax to £55,000 will not benefit many nurses. The current top rate of tax starts at £45,001 (3). At present you have to be on mid-point Band 8a or Band 8b and above to start paying the higher rate of tax. Under UKIP proposals you will have to be on top Band 8b and above to start paying the top rate of tax. Either way the vast majority of nurses will never earn enough to be effected by the top rate of tax, but raising both the tax allowance and top rate of tax will decrease the amount of money the government raises and that could directly affect NHS funding.

UKIP will give the NHS an extra £9 billion a year in funding; but the head of NHS England, Simon Stevens, has said that the NHS needs an extra £10 billion just to keep going (4). This doesn’t include any expanding of services, and last winter’s crisis showed that the NHS did not have any extra capacity to meet any increase in demand. The NHS needs to expand services as demand increases year on year, just providing enough funding to keep the lights on, at present, will not allow for this. As for social care funding, The Association of Directors of Adult Social Services estimated that £4.6 billion has already been cut from social care budgets since 2010 (5), an extra £2 billion is less than half of that. We have already seen that underfunding social care has a direct effect on increasing demand for NHS services.

They will also increase the number of nurses trained, which is desperately needed, but do not say by how many. It takes three years to train a nurse, plus the time to create these extra training places, so we won’t be seeing these extra newly qualified nurses for at least four years, and these nurses will not have the skills and experience of the nurses the NHS is already losing each day.

They say they will increase nurses’ pay but again they do not say by how much. Since 2010 nurses’ pay has fallen by 14% in real terms (6). Are they going to give nurses at 14% as soon as they get into office? If they don’t give exact numbers how can we hold them to their promises?

The NHS already has a 10% shortage of doctors (7) and back in November 2016 was facing a 3,000 short fall in A&E doctors (8). Training more emergency medicine consultants is a good thing, but without the support of a team of junior doctors those consultants are going to have a near impossible job, and will we be able to keep them?

A Royal Commission is a formal inquiry into an organisation and/or a situation and is usually chaired by a senior legal figure. Is it the right way to identify the problems facing the NHS and to provide solutions? Governments can ignore a commission’s recommendations in part or in whole (The Leveson enquiry into the culture, practices and ethics of the British press) and they can drag on at great expense (Royal commission into institutional responses to child sexual abuse). Also the government sets the remit of a Royal Commission, they will decide what the commission will look at and what they will not. A cleaver government could even insure that a commission comes to the conclusions they want to hear. A Royal Commission into the NHS could takes years to come to its commissions, years which could see the situation in the NHS becomes far worse.

She wrote nothing about UKIP’s policy to restrict immigration (9). The NHS relies heavily on non UK workers, 11% of all NHS staff and 26% of NHS doctors are non-British (10). We still don’t train enough doctors, nurses and other healthcare professionals to meet the demand, we need non-British staff for the NHS to survive.

I would love to put the other candidates’ answers to the same level of scrutiny but I cannot because none of the other candidates has bothered to reply to my email. I emailed my local candidates on the following dates (I couldn’t get all their email addresses at the same time):

• Labour candidate – email sent on 11/5/17
• Liberal Democrats candidate – email sent on 11/5/17
• Conservative candidate – email sent on 18/5/17
• Peoples Christian Alliance candidate – email sent on 18/5/17
• UKIP candidate – email sent on 26/5/17
• Green Party candidate – email sent on 28/5/17

So far only the UKIP candidate has replied to my email, and I emailed her much later than the majority of the other candidates. I was surprised that it was the UKIP candidate was the first to reply. I live in an intercity, multi-cultural, London constituency, not the natural home for UKIP. At the 2015 General Election UKIP barely campaigned here, so I wasn’t expecting to hear from her this time.

What I am most disgusted about is the lack of contact I have received from the big three political parties. They barely seemed interested in my vote, they are barely doing anything to win my vote. I have had campaign leaflets from them but nothing else, and all those leaflets were very low on facts and details. I know this is a snap election but it feels as if the one person my vote is important to is me, it certainly doesn’t seem important to five out of six of my local candidates.

Drew Payne

The Latest CPR Update

As a nurse I have performed CPR a lot of times in my career and the worst times have been when it was obvious that we had no chance of getting the person back. The futility of performing CPR when it is plain that the person had died and what we are doing was having no positive effect can be so depressing and can sap your strength. When the person in charge of such a resuscitation calls an end to it all it can come as a physical relief.

I was horrified to read the case of Jane Kendall (1). She was found guilty of misconduct and had imposed a Caution order on her for 2 years (2) because she didn’t perform CPR on a patient who had died; but the facts turn a different light onto it all.

Miss Kendall works in a nursing home, she was the nurse on duty, on a night shift in November 2014. During the night a Healthcare Assistant came to her and told her a resident was “unresponsive”. Miss Kendall found the resident had died. The resident had no pulse, wasn’t breathing and had no vital signs of life. The resident was “waxy, yellow and almost cold”, Miss Kendall said. She saw that the resident was dead and she didn’t start CPR. Death was confirmed by paramedics, later that day. The problem was that the resident didn’t have a DNAR in place (a Do Not Attempt Resuscitation notice) (2).

The police investigation found that there was nothing suspicious about the resident’s death. The police investigate all unexpected deaths. The Coroner found that the resident died from natural causes. There was nothing suspicious about the resident’s death (2).

The Nursing and Midwifery Council (NMC) found Miss Kendall guilty of misconduct. Their ruling talked about Miss Kendall “in the past put patients at unwarranted risk of harm” (2). This is an unbelievable claim to make. Miss Kendall didn’t harm a patient, she didn’t put any patient’s health or well-being at risk. What she didn’t do was perform CPR on a patient who had been death for a long period of time.

The NMC ruling (2) talked a lot about Miss Kendall’s actions and the “risk” she did and did not prose, but there was no discussion of the fact that the patient was already dead and neither was there any discussion of current policy and guidelines about CPR.

Firstly, in Miss Kendall’s evidence she said the resident was “waxy, yellow and almost cold” (2), with no pulse, not breathing or any vital signs of life. She was not describing someone who had just died but someone who died some time ago. Rigor Mortis starts within 2 hours after death (3), the signs of it are that muscles become firm and then rigid, starting with the small muscles in the face and hands, and a rapid cooling of the body (3). Her description of the resident as “waxy, yellow and almost cold” (2) implies that Rigor Mortis had begun. How successful would CPR be with someone who has been dead for so long?

Defibrillation needs to delivered with 3 to 5 minutes of someone’s collapse to give survival rates of between 50–70% (4). That is not death but when a person collapses with a cardiac arrest, the longer they have to wait for defibrillation the lower the chance of survival, but this time is measured in minutes and not hours. A person needs to be in a “shockable rhythm”, a condition that responds to defibrillation, and only 20% of people who have cardiac arrests outside of a hospital have a “shockable rhythm” when the paramedics arrive (4). Someone who does not a pulse and is “almost cold” will certainly not have a “shockable rhythm”.

“The decision not to attempt CPR is a clinical decision, if the clinical team has good reason to believe that a person is dying as an inevitable result of advanced, irreversible disease or a catastrophic event and that CPR will not re-start the heart and breathing for a sustained period.” Decisions Relating to Cardiopulmonary Resuscitation, a joint statement by the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (5).

It was not Miss Kendall’s fault that the resident did not have a DNAR in place, the management of the home needs to take responsibility for that, but Miss Kendall was the only nurse on duty when that resident died, she was the only clinical person there to make this decision.

The NMC’s ruling (2) makes no reference to any of this, it does not mention the Resuscitation Council (UK). They are the professional body that provides the most up to date and comprehensive guidelines on CPR, both in hospital and outside of it. They produce the Gold Standard for CPR guidelines, yet the NMC ruling does not mention them once. The ruling talks a lot about the “harm” Miss Kendall caused that resident and yet it does not discuss the fact that the resident had already died and that any attempt at CPR would have been unsuccessful. There is no discussion of the clinical situation here.

Miss Kendall did act outside her scope of professional practice (2), she verified that death had occurred when she had not been formally trained in certifying death. But she is a nurse of many years (She qualified in 1973 (2)), and being able to identify that all vital signs of life have stopped is something many nurses acquire during the cause of their career. If the NMC was so concerned about her doing this why didn’t they make recommendations about all nursing working outside of a hospital being trained to certify death? They didn’t (2).

There has already been concerns raised that nurses will now be pressured into performing CPR when it is obviously pointless following this ruling (1). To me, performing CPR on someone who is dead and with no chance of them responding is not respecting that person’s dignity in death, how can it be with all the physical force involved with CPR?

What worries me most, about this case, is the behaviour of the NMC. Their ruling shows should little understanding and discussion of the clinical situation Miss Kendall faced. There is no discussion of the fact that the resident had obviously died. They make no reference to any guidelines or evidence about CPR performed outside of hospital, and they do not mention once the Resuscitation Council (UK). The only guidelines mentioned in this ruling are the NMC’s own Code of Conduct for Nurses (6).

How can the NMC reach such a potentially far reaching judgement without any reference or discussion of national policy and guidelines, and no discussion of the evidence? This is such a narrow ruling, with no evidence backing it up. If my employer said I had to follow their new CPR policy, and the only reference in it was to another of the Trust’s policies, I would make such a stink about it.

This whole case highlights a problem I feel is at the heart of the NMC, the organisation is run by people who have no nursing or healthcare backgrounds. Jackie Smith, the NMC’s Chief Executive and Registrar, has a background in law, not healthcare (7). How can you regulate nursing when you have little or no experience of healthcare? This ruling shows how little the NMC understands about the realities of day to day nursing.

I work in the community. If I visit a patient at 10 o'clock in the morning and find they have died in the small hours of that day will have I have to perform CPR on them? The NMC says yes, yet they seem to know so little about the realities of my working life.

Drew Payne

Making My Vote Count, part 3

They say a week is a long time in politics, but in my experience politics also moves very slowly.

The Christian Peoples Alliance candidate has finally put his email address up on the Who Can I Vote For website, so of course I have emailed him. The Green Party candidate still hasn’t put his email address up there, so I still cannot contact him.

I have still not had any replies to my emails from any of the other candidates and it’s now just under two weeks until the election.

We have had election leaflets pushed through our front door though. One each from the Labour and Liberal Democrats candidates on Monday, one from the Conservative candidate on Wednesday, and one from the UKIP candidate today. None of these leaflets come even close to answering my questions. The UKIP candidate does have her email address on her leaflet so I have been able to finally email her today.

The Labour candidate’s leaflet said she will, if re-elected, “Revitalise our cash-starved health service ensuring it stays free, safe and reliable.” She doesn’t say how she will achieve this very lofty aim, nor does she say what she has previously done as our MP to support and “revitalise” the NHS. Her leaflet is high on highly emotional language and low on measurable promises.

The Liberal Democrats candidate’s leaflet talks a lot about Brexit, over half of his A4 leaflet is given over to what he claims to do around Brexit. His leaflet makes no direct promise for the NHS, but he does pledge to merge social care and NHS services in my borough, and “better funding arrangements”. Though he doesn’t state what these would be and were they would come from.

The Conservative candidate’s leaflet makes no reference to the NHS at all. Obviously this is of no concern to him. His leaflet does make three promises: 1, to support Theresa May in all her Brexit negotiations; 2, to “empower” local communities to take “action” on litter, dog mess and anti-social behaviour; 3, to “champion” the self-employed and small business owners. I cannot see any of these helping the NHS out of its current crisis or resolving our shortage of nurses.

The UKIP candidate’s leaflet had five pledges on it and one of them applied to the NHS. It was called “NHS Before Foreign Aid”, and stated, “Fund 20,000 nurses and 10,000 GPs; Scrap hospital parking fees.” She doesn’t say were these extra nurses and GPs will come from, seeing as there are already shortfalls in both professions, and one of her other pledges is “Cut Immigration”. If we can’t recruitment nurses and doctors from other countries we’re only going to add to the shortage, we’re certainly not training enough. She says nothing about NHS funding. She implies that the foreign aid budget will be spent on the NHS. Last year’s foreign budget was £12.1 billion (1). Last year NHS Trusts were underfunded by £2.4 billion (2) and by 2020 the NHS is expected to hand back £20 billions of funding in “efficiency” savings (2). The head of NHS England, Simon Stevens, has said that the NHS needs an extra £10 billion just to keep going (2). Also, Britain is in the top thirty richest countries in the world (3), why can’t we fully fund both the NHS and foreign aid?

I would to love to put these questions to the above candidates, ask them to fully explain what they mean and what they would actually do, but I can’t. None of them have replied to my email, so far I have been unable to find any local hustings were I could put my questions to the candidates, and no one has knocked on my front door conversing for my vote, certainly not any of the candidates. Neither of the local Labour or Conservative party websites list any opportunities to meet their candidates (The other four parties standing don’t even have local party websites, or none that I can find).

All the contact I’ve received from my local candidates, who all want me to vote for them, has been four, small leaflets. All of these leaflets are high on emotive language and low on facts and measurable promises. All of these leaflets were controlled by the candidates, they say what the candidates want to say. None of them even came close to answering my questions to them (4).

The basic MP’s salary is £74,962 (5). None of these candidates seem to be even putting in half the work to earn this high salary. Why should I vote for any of them?

Drew Payne

The Computer Says No

Who could have failed not to notice that the NHS was the victim of a cyber attack, last weekend? It was been splashed across our media that 40 NHS organisations and many GP practices were hit by this cyber attack (1).

The story broke on last Friday (12^th May), ransomware hit computers worldwide, ransomware encrypts (locks down) all the files on a computer and the hackers demand a ransom payment to unlock it, in this case it £230, but that payment was demanded for each computer not just for one organisation. The ransomware used a weakness in the Windows XP operating system at attack these computers (2), meaning older computers using this old operating system were more vulnerable.

Very quickly, over the weekend, our newspapers pointed the finger of blame, and it wasn’t at the hackers who created this ransomware. The Daily Mail quickly blamed managers for ignoring “warnings” (3). The Times claimed that failings in the NHS allowed the hackers to “walk in” (4). The Sun too blamed the NHS for being the victim of this attack and claimed patients’ record were in danger (5). Everywhere there were stories about the patient misery this cyber attack caused.

Amber Rudd, the Home Secretary, on Sunday, also pointed the finger at the NHS. She said the NHS “must learn” from this attack, and claimed that Jeremy Hunt (Health Secretary) had already instructed NHS trusts not to use Windows XP (6).

From reading all these reports you could be forgiven for thinking that this cyber attack only affected NHS computers, but that isn’t true. This cyber attack affected 200,000 victims in 150 different countries (7). Those affected by it included the Spanish telecommunications giant Telefónica, who owns the O2 network (8), Deutsche Bahn, Germany’s national railway service,  French carmaker Renault, a local authority in Sweden (9), and the Nissan car plant in Sunderland (10). I didn’t notice the tabloids or our government waging their fingers of blame at any of these companies or organisations.

But why was the NHS so vulnerable to this cyber attack?

Support for Windows XP ended on the 8^th April 2014 (11). Basically, Microsoft no longer issues up dates for it, updates that could protect against this sort of attack. Now the NHS had an agreement with Microsoft, it would pay Microsoft a flat fee, each year, and Microsoft would provide the software the NHS needed and keep it updated (12). In 2010, shortly after the Conservatives came back into government, in coalition, that agreement was suddenly cancelled (12). This moved the responsibility and cost of buying software and updates onto individual NHS organisations.

In 2011 the government cancelled the NHS IT system (13). This system was principally for patient records, but its cancellation meant individual Trusts had the responsibility for buying their own IT systems. This gave us different Trusts with different IT systems, many of them not compatible, and also again put the responsibility for maintaining these systems back onto the individual Trusts.

In 2014 the government warned NHS trusts that they needed to move away from Windows XP (14). On 8^th April 2014, the Cabinet Office issued a letter to all NHS Trusts telling them to “migrate” away from Windows XP (15), or if they couldn’t then to take out a Premier Services Agreement (PSA) with Microsoft, which each Trust would have to pay for themselves. The government did purchase 12 months of Custom Support, but Trusts would have to have a PSA to access it and Custom Support finished in April 2015. After then Trusts were left alone to make their own arrangements, and there was no extra money to help Trusts buy upgrades or even whole new computer operating systems for all their computers, which is never cheap.

NHS IT has never been the best, it has always lagged behind other industries. Since 2010, though, NHS funding has been cut, in real terms. Since 2010, NHS funding has only risen by 0.9% each year (16), less than inflation, and far less than the rising demand on the NHS and rising healthcare costs. Faced with increasing demand and increasing costs NHS managers had no choice but to reduce spending on capital projects, such as updating computers.

Jeremy Hunt was nowhere to be found over the weekend of the cyber attack (But they say Hunt never works weekends). It was left to Amber Rudd, the Home Secretary, to give the Government’s response to this latest NHS crisis, on the Sunday, instead of the Minister of Health. Hunt was door-stepped by the BBC on Monday morning but refused to answer any questions (17). He later gave an interview to the BBC (18) were he too wagged the finger of blame, claiming “lessons will be learned.” Under repeated questioning, Hunt denied that the cyber attack was due to underfunding of the NHS, and at one point tried to say the hackers actually targeted to NHS.

What seems to have coloured the response to this cyber attack is the opportunity to bash the NHS. So much of our media used it as a chance to attack the NHS, claiming it was the fault of managers and that “warnings” were deliberately ignored. The government was quick to point the finger of blame at the NHS, implying that they had done everything they could and the fault for the attack lay with NHS Trusts. Very few people sat back and asked the real questions about why the NHS was so vulnerable, why was the NHS still using such out of date software?

Again the NHS was vulnerable because of it chronic underfunding, it the same course that lead underpinned last winter’s crisis (19), and yet it was ignored again by our media and politicians. It seems that it is far easier to bash the NHS than admit a very uncomfortable truth.

Drew Payne