The tragic consequences of the depoliticisation of drinking water
Let’s do some simple maths on the best way to kill off old, vulnerable, sick people in hospital:
a) Average hydration needs for an old, sick, vulnerable person are about 1,500ml per day.
b) Old and sick people do not just gulp down a cup (roughly 150mls) of liquid at one go. One of the things about being old and sick is you’re not really up to that kind of thing, and often a good deal of support, help and encouragement is needed. They have come into hospital, after all, because they are too sick to look after themselves or be looked after by their family, or in their residential home. Some will be very dehydrated on admission, some will be very constipated. This creates a literally toxic mixture, unbalancing electrolytes, and leading to severe drowsiness and confusion, sometimes associated with totally atypical aggression.
The number of beds occupied by elderly people in the kind of situation, as a percentage of all beds, has increased over the last thirty years as a result of a) more old people in society; b) people leaving hospital more quickly as community services availability has improved c) no increase in hospital beds.
A rough average of 10 minutes is therefore estimated as needed to help an old, sick person to get into the right position and then get through 150mls of fluid. Anything less can descend into bullying.
c) An average NHS ward has about 30 beds. In a ward for old, sick people we might anticipate that a third or more (let’s say 10) will need a lot of encouragement to drink (see b).
d) A typical ward of this type might nowadays have four staff of varying skills mix and qualification, all working a 7.5 hour shift, giving a total staffing of 30 hours for the shift. Assuming no fluid intake at night, the hydration requirement means we need to get about half the daily intake (750mls) into the old, sick people in that time.
e) So helping people drink enough to aid their recovery will require a total of 5 drinks of 150mls for 10 people at 10 minutes a go. This is 500 minutes out of a total shift of 4 lots of 450 minutes, or 1,800 minutes.
So, at a reasonably conservative estimate, adequate hydration for an average number of old sick people on an average ward for old people requires a 27.7% of all staffing time to be spent on its facilitation.
That’s the maths. Do you start to see the problem yet? And we’ve not even talked about food intake yet?
Sure, it’s approximate but anyone who’s ever worked or been in a care of the elderly ennvironment will know that it is a roughly accurate picture of both patient dependency and staffing levels.
This oldperson-abusing problem is not rocket science. There are not enough staff.
Now let’s turn to what the NHS establishment make of all this. Here’s the Care Quality Commission has to say about the case of Alexranda Hospital in Worcester, named as a key culprit last week.
We spoke to a member of the medical team who said that for those people who can eat and drink independently there are no issues, but those that need support often face delays at mealtimes and with accessing fluids. They said that sometimes they prescribe drinking water on medication charts to ensure people get regular drinks and that this works. We saw examples of when this had been done. Ward staff said they were aware of people being prescribed drinking water and that this was done to make sure people get enough fluids and that sometimes patients are prescribed intravenous fluids too.
A ‘care and comfort round’ initiative had been introduced where staff complete a record of care provided throughout the day and night to ensure people are kept comfortable, have call bells and drinks within easy reach and that red trays are used where applicable. However, records we saw were incomplete and indicated that this was not happening as intended.
Let’s briefly first put to bed the sensationalist nonsense about ‘prescribing’ drinking water, before moving on to the more serious issue of actually getting it inside people.
‘Prescribing’ drinking water has been going on for at least 50 years. Most people at risk of dehydration have a standard fliud chart on their medical record, and it is very common to add in a note about the ninimum requirement (or a maximum amount where there is renal impairment meaning two much fluid will do harm). Ths fluid chart forms part of the normal medical record, and is often accompanied my ‘puish fluids’ in the notes. The fact that a few doctors may have chosen to make the same note on a medications chart is neither here nor there. Just stick ‘push fluids” into google and see what comes up. Here’s one for starters.
Turning back to the main issue, at no point in the CQC report is there any mention of staffing levels. The issue will be resolved, it appears, as long as the hospital trust improves its management and montoring, and “a report that says what action they are going to take to achieve compliance with these essential standards”.
Likewise, the Director of Nursing thinks it will all be ok as long as the staff take their responsilbities a bit more seriously:
Those of you delivering care and those with leadership responsibilities must ensure that the standards required and expected are achieved every night and every day and where this doesn’t happen there can be no tolerance. It is a privilege to provide care to those who come into our hospitals and this should never be taken for granted.
Not exactly a Root Cause Analysis, I have to say.
Not wanting to get left out, the Nursing Times – the lead professional publication – has this to say:
Assessing hydration and nutrition forms part of the high impact actions, and is an essential aspect of care. Any nurses who don’t understand its importance, and need to be told by a doctor’s prescription to administer water – as was the case in one of the hospitals – should reconsider their career.
If in doubt, it seems, blame the nurses for being in the wrong career.
No-one’s doing the maths.
Perhaps both the director of Nursing and the nursing journo might have been better – before blaming their nurses - to look at the Worcestshire Acute Hospital Trust’s plans for the 2010-11 financial year, and the key risk identified:
The next 3-5 years will be a major challenge for the Trust as it will be for the entire NHS in the wake of the severe economic downturn. Following period of significant annual growth of between 5% and 7% per annum, the next few years will bring either zero real terms growth or even a reduction as the government struggles to reduce public sector spending to repay the massive levels of government debt now on its books.
In spite of the fact that the government has honoured the levels of funding increase agreed for 2010/11 in the last comprehensive spending review of 5.5%, a considerable proportion of this sum is being topsliced by Strategic Health Authorities to support the costs of change that will be required to prepare the NHS for what is ahead. The following two years will see zero levels of growth and with the incessant increase in demand from an ever ageing population……..
The key risks facing the Trust in 2010/11 are as follows:
- Ensuring there is sufficient capacity to meet demand in the right place and at the right time.
- Ensuring that the Trust can ‘downsize’ and remove costs equivalent to any reduction in income resulting from the PCTs demand management measures.
- Delivery of the savings programme through robust planning, implementation and accountability arrangements, whilst maintaining safe clinical services and delivering challenging access targets.
Clearly, the final risk occurred, irrespective of all the clever planning and accountablity arrangements.
Let’s get to the bottom line.
In the end, the ongoing neglect and abuse of old, sick people (and it is going on in hospitals up and down the land as we speak) goes hand in hand with a simple refusal, by both Tories and the previous Labour government, and by the NHS establishment, to accept the bleedin’ obvious – that caring properly for people requires people.
I estimate that a properly staff ward for sick old people requires the same staff:patient as a cardiac unit. Instead, wards are often operating at less than half those levels. That is why neglect is taking place.
Call bells are not going unanswered because there is no-one to answer them, not because staff have a twisted professional ethic or inadequate training in understanding what the sound of a call bell means. Drinks are going undrunk because there is no-one there to help, not because nurses have forgotten that fluids are essential to life.
Speficially in the case of fluids, there is the option, of course, of ‘going American’ with a much higher percentage of patients attached to intravenous fluids than is the norm in British hospitals, where there has been a longstanding assumption on the part of medical staff that people will drink the required fluids if they physically can.
This raises its own issues, both ethical (a drip is a potentially dangerous and painful invasive procedure which might be considered unethical) and practical (it’s less easy to get around when attached to a big metal pole).
But in the meantime, the nursing profession (and its unions) need to stop whining on about professionalism standards, and how essential standards will be met if we really all try harder and make more action plans.
Instead, they need to do the maths.
And when they’ve done the maths, they need to repoliticise drinking water.