Really, Ms Brierley
This is an open letter to Sally Brierley, the Chair of the Nursing & Care Quality Forum, the creation of which was announced by David Cameron in January.
It concerns her letter of ‘initial recommendations’ sent to Cameron on 18th May.
Dear Ms Brierley
I wish to offer my comments on nursing and care quality to the forum, and I do so in the context of your letter of initial recommendations to the Prime Minister of 18th May. I will cover three specific issues: membership of the forum; staffing levels; and intentional rounding.
Membership of the forum
In your opening preamble you say:
When you announced your intention to set up the Forum, this was against a backdrop of high-profile failures in the quality of care, from isolated cases reported in the media, to systemic problems at Mid Staffordshire NHS Foundation Trust and Winterbourne View. These cases have demonstrated that there are problems with the quality of some nursing care, and some of these problems are very serious.
Given your concern about Winterbourne View, it seems odd that your forum contains no members from the private care industry.
While you might wish to argue that some quality of care issues are generic to both the NHS and private sector, it would surely be remiss of the Forum not to examine whether there are any factors specific to private care which create the risk of patient abuse of the type seen at Winterbourne View. Surely, therefore, the Forum needs someone on it with an understanding of the private care industry.
I recommend that you take early action on this point, so that issues relating to private sector care are adequately addressed by your forum.
The professional press has picked up quickly on your initial finding that:
We heard overwhelmingly that staff are concerned about staffing levels and skill mix within their teams and the subsequent impact that this has on the quality and safety of care, and people’s overall experience of the care they receive.
You go on to make the central recommendation that Boards or their equivalent should conduct bi-annual reviews of staffing levels and skill mixes, and that the Care Quality Commission should seek assurances that these are being conducted.
This is fine in itself, but it is not enough. Managerialism is fine when there are sufficient resources to manage; managerialism becomes part of the problem when there are not.
I am therefore most concerned that you feel able to say to the Prime Minister, in your opening statement:
Of course, more money and more staff would always help, but we need to ensure we use the resources we have available to deliver more effective and efficient high quality care. Nurses need to rise to this challenge, backed by strong leadership at every level.
This reads to me like an early abdication of responsibility on the part of the forum, and yourself as its chairperson.
I see nothing in the remit of the forum which requires that it offer recommendations only within the constraints of existing funding to NHS Trusts and private sector organisations. If it transpires that, ultimately, there are simply not enough resources being made available to ensure good quality care – and this is what your early findings do suggest – then it your forum’s responsibility to bring this to the attention of the Prime Minister (assuming you keep up your correspondence to him), and argue for more resources.
You will, I am sure, have seen Monitor’s most recent set of financial assumptions, setting out the eye-watering level of ‘savings’ that Trusts in both the acute and non-acute sector are being expected to make over the next five years, and further to the massive reductions in resources they have already suffered. The staffing level/skill mix problem is only going to get worse, and if your forum chooses not to engage with this reality, then I am afraid it will become part of the problem itself, rather than part of the solution that both you and I hope it will be.
I recommend therefore that at your next forum meeting your lead agenda item should be a revisiting the parameters you have set yourself for your work, in light of your key early findings of resources constraints, and that subsequently you write to the Prime Minister to inform him of the outcome of your decisions.
I note that the forum wants to:
accelerate the implementation of person centred approaches such as ‘rounding with intention to care’ – where every individual receiving care knows they will have at least hourly contact with staff – and we believe that wherever possible, handovers should be done alongside and involving those we care for. Therefore, we will identify and work with demonstrator sites in a range of care settings (including hospitals, care homes, mental health and community settings) and use the lessons learnt to support others on their implementation.
Clearly you will be aware of the issues relating to patient confidentiality with bedside handovers, and I am sure you will be addressing those.
However, I wish to raise a much more fundamental concern about ‘intentional rounding’ which I feel has been insufficiently explored to date, and which governmental/prime ministerial pressure to be seen ‘to do something’ about care quality risks being wholly set to one side, with serious negative impacts on that care quality in the medium to longer term.
At his visit to a Salford Hospital on 6th January, the Prime Minister announced the creation of the forum you now lead. At the same time he made the pronouncement that he was in favour of ‘hourly intentional rounding’ and that he wanted to see it rolled out across hospitals nationwide.
This was, frankly, an insult to the nursing profession. Imagine, by way of comparison. if the Prime Minister had visited an operating theatre on the same day, heard from an anaesthetist that he was now using a new anaesthetic drug which appeared to offer less post-operative side effects, and then announced on the spur of the moment that he [the PM] now wished to see the use of this drug rolled out nationwide. Imagine, then, the uproar that would have ensued from the medical profession.
Yet the nursing profession appears to be expected simply to say ‘Yes, Prime Minister’, and get on with ‘rolling out’ a method of nursing which is a) unproven in terms of its medium-to-longterm effectiveness; b) despite the addition of ‘intention to care’, still bears some of the hallmarks of the ‘back round’ that both you and I were subjected to as young nurses, and which a newly confident nursing profession moved on from in the 1970s and 1980s towards models of care which did not depend on mindless routines, but which took individual patient needs into account.
I note that the forum is wary of intentional rounding becoming an exercise in box-ticking. Yet I fail to see how it can realistically be anything other than that (though it will be box initialling rather than ticking). Daily rounding sheets that I have seen have between 120 and 150 different boxes where an initial must be placed to prove that the care has been provided, or the question asked. That is 120 boxes every 24 hours for every patient. How can that not become an exercise in itself?
There is a rich body of research literature – sadly apparently untouched by the nursing profession – known as implementation studies, which looks at the way in which policy is implemented ‘on the ground’, largely beginning with the groundbreaking work by Michael Lipksy in the 1970s (Street Level Bureaucrats: Dilemmas of the Individual in Public Services).
This research studies the way in which policy imposed from above is inevitably interpreted by those tasked with implementing it, and how in situations where both resources are constrained AND worker initiative is restricted, the outcome is often one of ‘alienation’ and degraded public service.
You can see this process of alienation and degraded service on hospital wards today. Where resources are scarce, and staff are undervalued, you get the inevitable result of staff ‘shutting down’ their empathy as a coping mechanism, and the results are all too clear: nurses ignoring patient needs, huddling at the desk in a mixture of resentment and guilt, unwittingly part of a downward spiral of the type seen at Mid-Staffordshire.
The introduction of intentional nurse rounding will – I can guarantee – lead, perhaps after initial improvements, to worse care in settings which are already under staffing pressure. Excellent nurse leadership may slow up the downward spiral in some cases, but in most cases even that will not help. From there, mangerialism will again kick in, with the blame attached to staff when it turns out that intentional rounding did in fact become a giant, cynical box-ticking exercise, and that patients in their care become even more dehumanized.
I urge the forum to get a grip of the implementation studies literature to which I refer, and to look back in history to see why routinised care was dispensed with by the nursing profession first time round.
The forum should then think again about its ‘demonstrator sites’; the evidence base for intentional rounding simply does not exist, especially in terms of its longer term effects, to justify ‘demonstration’ over ‘pilot’, and as noted the move towards national rollout in compliance with the Prime Minister’s uninformed wishes will not just be dangerous for patient care; it will be an expression of abject acquiescence on the part of the nursing profession, with your forum as key representatives, and a massive step back for the profession in terms both of its credibility and self-confidence.
Paul Cotterill, ex-RGN (registration now lapsed as result of ubiquitous 1980s nursing back injury)