11 March 2011

Stafford Hospital: what the Royal College of Nursing saw.

The thing that you keep finding with the Stafford Hospital story is that there are so many things that don’t quite fit.

The press have their simple story of a uniquely bad hospital where hundreds of people are dying of poor care, and then right in the middle of the healthcare commission investigation you get this letter from the CEO of the Royal College of nursing talking in glowing terms about his visit to the hospital, and the great work that is happening there. This was a letter that in the words of the inquiry caused the pressure group to "take umbrage." It is perhaps characteristic of an inward looking group, which has been successful in commanding the attention of the press, that they assumed that Peter Carter must know all about them and was deliberately contradicting their story. The fact was that he is a busy man, he knew nothing about them at this stage and he was merely reporting the very positive visit he had to the hospital.

The Royal College of nursing is of great importance to the Stafford Hospital story, because this is the body that represents the nurses. Poor nursing care is central to the stories that the media has to tell on Stafford Hospital, and to other hospitals highlighted by the recent ombudsman’s report.  The Evidence of Peter Carter, CEO of the RCN gives us a lot of highly useful information Full transcript.

There is a useful snippet if personal information about Peter Carter. He says of himself:
"I've built my reputation on calling it as I see it. And I certainly wouldn't have been used as an instrument to do someone else's bidding". He also tells us of the highly relevant subject of his thesis completed 1998 “was on why nurses abuse patients”
The royal college has a dual role. It is the body which advises on the professional standards of the nursing profession and it is also a union for nursing staff.
Peter Carter has a responsibility for the entire RCN. Funded by membership subscriptions there is a staff of 300 staff at head office; they take care of its 416,000 nursing staff in hospitals, and care homes. As someone with such a huge organisation it is clear that he has to rely on the information that is filtered up to him.
It was clear that in the case of Stafford he was heard nothing. This is not unusual. He would only hear about concerns in a particular hospital in exceptional circumstances.
Sue Adams is one of the RCN’s Stewards at Stafford, Her personal experience is of staff who were under pressure, but were coping, and that she received no information of any serious concerns about patient care. She also says that because she had to fit her union duties in on a voluntary basis around her own heavy workload, that she was in no position to go hunting for problems. It is clear that her superior in the union was also coping with a heavy workload, and was seen by some of the staff as too close to management to be an obvious channel for complaints about workload.
If we look beyond Stafford, the RCN carried out research that correlates staff mix – the ratio of Qualified to unqualified staff, to quality of care.  It is clear that if this falls below a certain level then there is a strong likelihood that patient care may suffer.
Sue Adams own evidence also shows in a pretty clear way what happens when the ratio of patient to staff levels is badly balanced

 I was absolutely aware of the staff shortages and the lack of qualified staff on duty in some areas that had been reported to me. But I can honestly say that none of the staff were saying that the nursing care was not being given.
You've already described how nurses would come and speak to you about concerns they had, and indeed you say in your statement that, at times, your members had burning issues that they wanted to discuss with you, but not about failings in nursing care.

They felt that they were trying to give the best care they could with the numbers that they had, but weren't able -- weren't able to deliver the care that they knew the patients wanted, needed and deserved. With the best will in the world, if there were three nurses on duty and five people buzz for a commode and each patient needs two nurses to get them out on to the commode, they can only help one patient at a time, and by the time they get to patient 5, that patient hasn't had the care that they need and may well have been incontinent
Sue said that there were real concerns about the staffing levels and staffing mix and that she actively encouraged staff to put in incident forms whenever they felt the staffing levels were wrong. This may possibly explain the persistent stories of someone having seen complaints forms in a bin. This was mentioned in Sue Adams evidence, but the details of this are not clear. Maybe we will eventually hear the full facts of this, but then again maybe we will not. There is nothing certain about it.

Robert Francis has clearly understood the crucial question of staffing levels and mix and asked good questions about who should be responsible for stipulating staff and staff mix levels. Peter Carter was very clear that this is something that it is completely inappropriate to leave to local discretion – it has to come from Government and it needs to be enforced by the Care Quality Commission. This is a message that needs to get through to this government as it directly contradicts the direction of the health bill proposals.

Well, first of all, Mr Francis, I actually think it should start at government level. I think it's wholly unacceptable that this is left to local employers. So, first of all, from the top there should be a compulsion on people to do impact assessments and to be clear about what their staffing is. But I would also put this into the remit of the Care Quality Commission. And I think that with their inspections and visits, they should have a real focus on staffing levels and they should be tasked to take employers to task on this.
Peter Carter was asked in some detail about his visit to Stafford and the letter that he wrote to the press which gave such offence to the pressure group. he had been shown a series of presentations on different wards which included work they were doing on infection control, and monitoring pressure sores  He also did what he habitually does on such visits and had a private discussion with several groups of patients.

Here are some of the exchanges about that visit.

When I go on visits I always obviously talk directly to nurses and other staff, but one of the things I always ask to do, and it's never denied to me, is I ask to  speak to patients, and I think that's really important. And how I do this, I've got a kind of tried and tested way of doing it, is I put it to the -- the people that are escorting me around "Well, look, I want to ask patients at first-hand what they feel about their care, but it's going to be pretty intimidating if there's a small entourage with me". You know, you can hardly say to a patient "How do you feel about the nursing care?" if there are four or five nurses around. So what I do is I tend to go into, say, a four-bedded dormitory by myself and I simply say "Look, I'm Peter Carter from the Royal College of Nursing, I'm fishing here today, do you mind if I ask you about your care?" I do it in the a very low-level way. I've never been refused and people -- people talk.And at my visit to Mid Staffs, all of the people  that I spoke with, could not have been more fulsome in their praise. I mean, look, I had -- I didn't know any of the people at Mid Staffs. There's no pre-existing allegiances. I mean, had people been saying to me "I'm  glad someone's asking me, you know, I've got some real concerns about what's going on", I would have raised it with Helen Moss, I would have said -- but it was -- it was entirely the opposite. Really, really glowing  tributes about what people were saying on the wards that I visited.

He explains this apparent contradiction in a simple way – A hospital is made up of a series of microclimates. Individuals matter. A gifted sister can make a great difference. Some wards will run well, others not so well. This does give us a clear picture that at the time when the HCC investigation was in full swing there were certainly some areas of the hospital (it could of course be argued that he was only shown the good bits) where things were not merely adequate, but very good.

I'm astonished that -- I mean, I consider myself experienced. I'm astonished that you could go and visit a few wards and get such a really good feel-good factor, to then subsequently know that in part -- and we've -- we've got to be clear, it's parts of the hospital. The Healthcare Commission's inquiry was not into Mid Staffs per se. It was into the A&E, the medical wards and some other aspects of care. And it's not uncommon, and I've used it my statement, that hospitals are a series of microclimates. You can go to one ward with an excellent ward sister that's well managed and it's everything that you could wish. You can go to another ward and the care can be very poor. And that, I think, is what confuses people. All I'm saying is I called it straight and what I saw it felt really good.
He later returned to the hospital before the issue of the HCC report and held an open forum attended by 92 staff. Staff at this forum told him of their appreciation of his letter

Look, we feel the whole hospital has been traduced here and yet many of us provide excellent nursing care". And in fact some of them were appreciative of my letters because they felt that reflected the truth.

But also the staff were also more open about the problems they were experiencing in other areas. I mentioned the open forum that I had, the word "Beirut"(which has become a part of the mythology of the Stafford hospital Story) in relation to EAU was mentioned then.
When the Healthcare commission report and the press frenzy that accompanied it came out this came as a great shock to Mr Carter, as it did not accord with his experience, and he had certainly not had any indication of the level of problems raised by the report through the RCN channels.
There was an exploration of the reasons why he had not heard anything. This is the central question that the Inquiry is trying to ask, and it always does come down to a complex mix of reasons. It is from the evidence of an increasing number of the witnesses pretty clear that if there were problems they were not at all obvious even to those who were working in the hospital. There is still no sense at all that anyone one understands the scale. Are we looking at a handful of individuals in a few wards, or were the problems more widespread?
The inquiry explores this further – which is right – because if the indications are not coming from the nurses who are there giving the day to day care, then where are they going to come from.

“ I think you're critical, I think, of Monitor and the PCT and other agencies for  not spotting what was going on. But, of course, if your  members aren't coming forward to you, if there's a general culture of people not being open about what's  going on, it's very difficult for anybody to find out, isn't it?

I genuinely believe the vast majority of the nurses at  Mid Staffs were nothing other than decent people, it is fair to say that, for a whole collection of reasons, which I'm happy to explore with you, people were not more open about the deficiencies in care. Now, I've already given one explanation is that people felt, well, if you're cutting 150 jobs, there was a heads down mentality, and there's also evidence that a lot of good nurses decided to leave
Robert Francis askes about Whistle blowing. Does it work?

Yes, Mr Francis. Look, I think there's a huge problem with this. I mean, first of all, I'm sure you and your colleagues will be aware of this that sometimes ministers think that in Whitehall you have a piece of legislation and it solves the problem. And in my experience that's rarely the case.
A particular issue that Peter Carter raised which I feel has a crucial bearing on the future of the quality of care is the matter of Nursing care assistants. I think it is clear that he believes we are looking at care being delivered by under regulated, untrained and un-unionised workers. He finds that a matter of concern, and so do I.
For the record, I think it's important to clarify, the RCN has 416,000 members, only 8,000 are healthcare assistants. So healthcare assistants are a tiny part of the membership. I just thought that was right for the record. The problem is the vast majority of healthcare assistants are not in any organisation at all. They'd be very welcome to join the RCN. In addition to that, the RCN is currently lobbying that we think healthcare assistants should be properly regulated and they should be trained. If I may go on  just to add, you have -- have a phenomena at the moment -- and by the way, through -- across all sectors, both care homes, residential homes and hospitals, there are nearly half a million healthcare assistants. So it's a huge component of the workforce. And the problem at the moment is in the absence of any mandatory training, it's left to local employers. Now, there are some trusts that do it really well. They employ people, they induct them, they train them and teach them all of the skills that are needed. Sadly, at the at the other end of the spectrum, we've come across instances where people have no training at all. They're literally given a tunic, it looks like a nurse's uniform. They're put on wards and they pick it up as they go along. Now, we say that's wholly unacceptable.
Mr Carter was asked about some aspects of the HCC report.
He makes it clear that he has no knowledge of the mortality statistics which he sees as the responsibility of the trust, the PCT and the SHA.
Perhaps because of this gap in his specific knowledge he accepts what he has heard about the HCC report without question.
But there are issues raised in the HCC report that did really upset him, as they did anyone who was concerned about the provision of good health care.
Receptionists were triaging patients in A&E, patients being left in excrement, nurses in the cardiac unit had not had the cardiac sciences training and so were turning off the cardiac monitors, intravenous infusions were not running properly.
All these are real and serious concerns. All have been dealt with. What neither the HCC report or any of the subsequent reports have really told us is the extent of the problem.

What I feel from reading Peter Carter’s evidence is that he has got to the heart of the matter. The hospital is not a single entity, it is a series of microclimates which are all behaving in their own unique way. There is nothing contradictory in saying that there was very good practice side by side with very poor practice.

I believe there is also a fundamental message here. Care in the end is delivered by individuals. If we want good care we have to look after the people who are delivering it in the right way. Competition and driving down costs is very unlikely to deliver the quality of care that we would like to see, and we have to encourage staff to find their voice and know that they can and should speak out strongly when things are not as they should be.

There is also a message with regard to the role of the press. The press have been too concerned to deliver a simple coherent story. They would be serving us better by showing the facts in their full complexity. Good and bad co-exist. If the wellbeing of the staff is central to the quality of care that is delivered then what has been perceived as a prolonged and unbalanced press campaign to vilify the staff is counterproductive.