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Whats wrong with the NHS? (If you are old and frail)
- David Oliver (12 November 2007)
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An unhelpful piece
- peter j mahaffey (12 November 2007)
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Ignorance or apathy?
- Wendy A Holden (13 November 2007)
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David Oliver, senior lecturer, geriatric medicine University of Reading, Institute of Health Sciences, Reading RG1 5AQ
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Editor The personal view “so you want to know what’s wrong with the NHS?” was harrowing – all the more so because the deficient care as described was for the mother of someone presumably known by most of the staff to be a health professional – which would generally tend focus the mind! Of course many service users do not experience such consistently poor care and “exit” surveys still show fairly high general satisfaction levels. However, there is still much objective evidence of “undignified and indifferent care” and “deep rooted and persistent attitudes by hospitals and staff to older people”,1 with hospitals still not being “age proof and fit for purpose”.2 It is no co-incidence that the author’s mother was ageing and suffering from mental health problems. It is the old and the mentally ill who are still likely suffer discriminatory attitudes long since considered unacceptable in other groups. And the tale of someone already suffering from delirium, being moved repeatedly and inappropriately, thereby worsening their disorientation is all too familiar.3 Some of the problems described are down to an inexcusable lack of professionalism pure and simple. There are also openly ageist attitudes in society which infect clinical professionals. Look no further than patients with legitimate medical illnesses being labelled with “acopia”, “social admissions”, “bed blocking” or worse (“crumble”, “gomer”), rather than being given an adequate diagnosis and treatment plan. Despite the fact that by far the biggest activity in hospitals and primary care comes from older frailer patients with long term conditions, most medical and nursing students still state that they have no wish to work with older people - an unglamorous and low-status endeavour. The amount of specialist training in undergraduate and postgraduate curriculae on the care of the elderly or mental health issues does not reflect the fact that this will form much of the work of future health professionals – if they are to provide a public service based on need. Although the 2001 Older Peoples’ NSF4 emphasised the need for education and training for all professionals caring for older people, there were no earmarked funds and no “must do’s” and this manifestly hasn’t happened. There is some hope now with the HealthCare Commission’s plan to use inspection and performance management to improve these vital aspects of care.5 However, we still have a system where there is a clear hierarchy of performance targets, with “basic care” of the type so clearly lacking in this case, well down the list, whether in hospital performance indicators, in the primary care. The recent Healthcare Commission report on the Maidstone and Tunbridge Wells Scandal6 showed all too clearly how external targets distort priorities. And the whole performance framework for the NHS tends to encourage a view of unselected acute older patients as a loss leader and a problem for the system. Finally, we have a bizarre situation in which the Prime Minister mentions “matrons” seven times in his party conference speech, whilst beyond the rhetoric, experienced nurses who should act as mentors, educators and role models are financially rewarded for leaving the bedside and taking on general management roles. Once they have taken the corporate shilling, their ability to remain as an independent, “challenging” advocate for patient care is lost. Whilst there can be no excuse for the total lack of care or professionalism described by the author, there is plenty we could do with system reform to prevent a repetition of this tale. If the same performance pressures were applied around basic care and communication as exist for outpatient access times or financial balance then perhaps directors of nursing and trust boards would take more of an interest. 1. Audit Commission, Healthcare Commission, Commission for Social Care Inspection. Living well in later life. London. 2006. 2. Department of Health. A new ambition for old age: Next steps in implementing the National Service Framework for Older People. Department of Health. 2006. London. Available at www.info4local.gov.uk/searchreport.asp?id=28951&frompage=whatsnew&subject=21 (accessed 17th Dec 2006) 3. Royal College of Physicians. Guidelines for the diagnosis and management of delirium. London. 2006. RCP. 4. Department of Health. The National Service Framework for Older People. Department of Health. 2001: London. Available at http://www.cpa.org.uk/cpa/policies_on_ageing.html (accessed 21/08/07) 5. Healthcare Commission. Caring for Dignity. London. 2007. HCC 6. Healthcare Commission. Investigation into outbreaks of clostridium difficile at Maidstone and Tunbridge Wells Trust. London. 2007. Healthcare commission. Available at http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/11_10_07maidstone_and_tunbridge_wells_investigation_report_oct_2007.pdf Competing interests: None declared |
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peter j mahaffey, consultant surgeon bedford hospital
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Those of us who work in the declining NHS all know the faults and the daily problems which we and our patients have to suffer, but really, it doesn't help anyone to publish this sort of anonymised rubbish in a journal which takes itself seriously and is supposed to reflect some kind of science. Once upon a time the BMJ was a serious journal. Its decline to little more than a news magazine will not be halted by publishing the kind of stuff which is more properly suited to the Daily Mail. And in which other country would the main organ of medical information descend to this kind of public washing of dirty linen to an international audience? What kind of author feels he/she has to hide his/her name, and why does the BMJ entertain such anonymity? Competing interests: None declared |
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Wendy A Holden, Locum Consultant Rheumatologist Sandalwood, Cock Lane, Southend, Reading, RG7 6HN
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Last week I was invited to teach a group of medical FY2 trainees on several aspects of rheumatology. The talk was organised round various rheumatological clinical situations that they might encounter on the wards such as acute monoarthritis. The talk was interactive, problem-based and largely photographic to minimise boredom. In spite of this, the apathy in the room was palpable and several people continued their own conversations throughout. Thinking I was asking a simple question, I invited thoughts on the causes of an abnormal chest X-ray in rheumatoid arthritis. One junior either couldnt or wouldnt offer an answer to that issue or the follow-up question of naming any cause of an abnormal chest x-ray. The next respondent said "amyloid". Are new shift patterns and competency-based training leading to a generation of doctors who have so much bleep-free time or time off after working nights or training in marginal areas that they have very little clinical knowledge or experience, or do juniors just not care any more? Competing interests: None declared |
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