Monthly Archives: July 2013

‘Time-poor nursing’- when will government understand ‘management’ strategies more suited to a car plant do not work on hospital wards?……..

Whilst The Guardian highlights the negative impact of ‘time-poor’ nursing practices on patient care it needs to be emphasised organisational structures that support a mechanistic approach also need to be addressed.

As the BMJ publishes a report which suggests nurses are being forced to “ration care” I am beginning to wonder if this government is incapable of learning from past mistakes. Since being in power we have had pronouncement after pronouncement on the need for ‘compassionate care’ leading to the vilification of many who try to provide such care, but who are impeded by organisational structures and ‘management’ strategies more suited to a car plant than a hospital ward trying to care for individuals when they are ill. Nursing staff do not generally enter the profession to provide poor quality care, on the contrary the majority want to provide the best care possible, however, once in the system the working practices in many hospitals seem designed to stop this occurring. Research suggests staff develop ‘social defences’ to cope with the disparity they experience.

Jaques (1955) initially used the concept of social defences ‘‘to refer to unconscious collusion or agreements within organisations to distort or deny those aspects of experience that give rise to unwanted emotions’’. The concept was developed later to take into account structural factors ‘‘arguing that social defences were the result of poor organisational structures. This provides a useful concept to begin to understand how structural systems interweave to produce an environment where poor quality care might flourish in a bid to meet the needs of the organisation and make care systems affordable.

Research suggests Nurses use social defences to cope with high levels of stress and anxiety associated with the job. Defence mechanisms include care for patients split into individual tasks undertaken by a number of nurses, one nurse performs the same task to many patients rather than working with one patient to provide all their care. This facilitates a distancing between the patient and nurse, which protects the nurse emotionally. Organisational factors support a depersonalised approach by moving nurses around wards, which then allows the nurse to distance themselves from patients so as not to become emotionally involved. Other social defences include a denial of feelings and over emphasis on professional detachment and strategies to reduce anxiety around decision-making, for example working in prescriptive ways, performing prescriptive tasks, and delegating decision-making. This may be reminiscent of current care provision within hospital and residential settings, where the lack of connection between patient and carer arguably facilitates an environment in which poor quality care becomes the ‘norm’.

Research by Calnan et al. (2012, p. 1) on the provision of dignified care for older people in acute hospitals highlights this point when they ‘‘found a lack of consistency in the provision of dignified care which appears to be explained by the dominance of priorities of the system and organisation.

Structures that depersonalise the caring relationship will not lead to the delivery of compassionate care. Compassionate care is more than a mechanistic task, it is emotionally and psychologically draining, staff need support not an organisational structure that is unsupportive. This government has to stop pointing the finger at the previous administration and learn from their mistakes.

I am reminded of the ‘Peter Principle’ which asks “Why does history keep repeating itself? Because nobody ever listens”. Quite.

(If you would like to read more on ‘Social Defences’ you can access a journal article I have written on the subject published in the Journal of Adult Protection)

NHS Direct and 111, why the surprise?

Why the surprise over NHS Direct?

As the Independent reports on NHS Direct pulling out of providing 111 services I wonder how the government might not have seen this coming?

Probably because faith in the free market is unshakeable across government as it chooses to ignore evidence of its failure. The free market is seen by many as the only way forward to address future resourcing issues. However, the re-branding of healthcare as a commodity ignores some simple ‘free market’ truths, pointed out by the economist Adam Smith several hundred years ago;  the purpose of the free market is to generate wealth for those who own the means of production, or the ‘masters of mankind’ as Smith christened them, it is not a charitable endeavour but a single-minded system driven by cash not compassion, who Smith suggested had a ‘vile maxim‘  of  “all for ourselves”.  The ‘masters of mankind’  in Smiths time were the merchants and manufacturers who supported policy that enabled them to make more profit, they were not concerned with how such policy and their actions might impact on others.  Today the ‘masters of mankind’ appear to be companies like NHS Direct or ‘big pharma’, financial institutions and banks, insurance companies, private healthcare providers.

This really should not come as a surprise as we have already seen some of the potential problems that can arise in the marketisation of social care. At a macro level those private institutions who have already taken over some areas of care provision   have been found lacking, which does not bode well for extending this strategy accross healthcare.  Take, for example, HSBC who were fined £10.5 million last year for mis-selling care bonds to older people.  The Financial Services Authority found unsuitable sales had been made to 87% of customers, with the average age of those who purchased bonds being 83 years of age, many of whom having already died before the scandal came to light.  Whilst £10.5 million might sound a lot it’s not for a company who was recently exposed as allowing the laundering of at least 7 billion dollars of drugs money through its bank and has set aside 700 million dollars to cover fines.

The selling of care related products and services by the private sector can leave individuals vulnerable in a variety of ways, look at the doubling of the number of private care homes going bankrupt leaving older people without secure housing or care provision. Latest reports in The Independent suggests nothing had changed as the bailiffs are set to move in on some care home providers.

Arguably, the ‘free market’ is anything but ‘free’.  A favourite of Mrs Thatcher, economist Friedrich Hayek compared the free market to a ‘game’ where there are winners and losers suggesting trying to regulate the market in the name of social justice was a waste of time. The current government, and opposition, appear to believe there is only one game in town when it comes to the future of our health and social care sector, they are wrong.  

The case against an exam culture in education: In Finland no targets = higher quality provision and attainment

Finlands education system is one of the best in the world, and it does not rely on tests, targets and league tables. Could this show us a way forward?

As ministers look at how to prepare primary school children for secondary education, how do we turn the system around? Well I wonder if the answer lies in Finland. An interesting article , about the education system in Finland, caught my eye a while ago and got me thinking. Apparently Finland’s education system is the best in the world, although this has not always been the case. Following failure in the 1970’s the whole system was reformed, and the reforms seemed to have worked, and even cost less than when the education system was failing.

So what did they do? Introduce additional tests, targets, performance indicators, outcomes, privatise the system to increase competition and consumer choice to drive up educational standards? Well, no, just the opposite really.

Firstly, there are no league tables in Finland, the main driver of education policy is a vision focused on ensuring all children have access to the same opportunities to learn in a good school, wherever the child lives and regardless of the childs economic background. Cooperation between schools rather than competition underpins this ethos, as does a belief in the ability of individual schools to achieve this without centralised targets from government or regulation. Teachers are valued as professionals and as such are trusted to assess children in their classroom using independent tests they create themselves. If they do not feel it is beneficial to the childs well-being they do not test the child. Inclusion in tests are determined by whether it positively affects the students learning, not whether it increases students scores or meets a performance indicator.

The bit that really caught my imaginaton when reading was when the interviewer asked about the accountability of the teachers and those who run the school.

‘Salberg shrugs. “There’s no word for accountability in Finnish” later on suggesting “Accountability is something that is left when responsibility has been subtracted”

Whether this is true or not I do not know as I do not speak Finnish, however, it is an interesting notion that by acting responsibly accountability is not an issue. In Finland teaching professionals are afforded prestige, decent pay, and a lot of responsibility, which they evidently fulfil with gusto. So the question of ‘accountability’ seldom arises. If it does it is dealt with by the head locally.

And believe it or not but all of this has been achieved by not privatising education, that’s right not privatising education. There are no private schools in Finland, only a small number of independent schools exist in Finland but even these are publicly funded. None are allowed to charge fees, and there are no private universities either. The focus in public sector provision of education is on equity and shared responsibility, not choice and competition. Hmm can we learn anything from this?

At present public trust and confidence in the public sector must be at an all time low, however, to regain trust we need to see real change, a change in direction that is new and imaginative. One of Finlands key success factors has been a recognition that learning from past experiences can build a better future. Can we do the same?

Katie Hopkins exposes the darker side of ‘Big Society’……….

Supporters of ‘Big Society’ talk about a connected society, one understood in terms of affection, friendship and regard for one another. The political philosopher Edmund Burkes much quoted ‘little platoon’ emphasises how such connections not only benefit individuals and families but society as a whole.

However, it would appear if you are called Tyler or Charmaine, or are an ‘unattractive’ girl, you will only be able to join certain platoons, presumably those located on an inner city wasteland, probably near a MacDonald’s!

Katie Hopkins opinion was revealed on ‘This Morning’ last week, when she suggested she would not let her children associate with other children with what she considers ‘low class’ names. Whilst on Saturday we had John Inverdale on the BBC’s radio 5 Live making derogatory comments about Wimbledon womans champion Marion Bartoli’s looks, or more to the point from his perspective, her lack of looks.

It’s a storm in a teacup, just harmless media fun! Maybe, after all it’s given Hopkins some much-needed media exposure, and Inverdale some much-needed exercise as he furiously back pedals. However, there are more serious points to be made here.

What Hopkins is advocating is we judge a child by some reference point that is nothing to do with that child, which tells you nothing about that particular child or who they are as an individual. They are a ‘stereotype’ child, who, in Hopkins world will be excluded from her household (which actually if I were a parent I would be glad of as I would not want my child to associate with anyone with such shallow opinions). Sadly, many children grow up being unfairly judged and excluded from society for irrelevancies such as their family history, religion, the colour of their skin, their sexuality, where they live, all kinds of things which the child actually has no control over, and whilst this incident might seem trivial isn’t it a sign of that not so nice side of human nature we all possess, and which given the right conditions can grow into something much more damaging to others such as prejudice and intolerance?

Having recovered from Hopkins I then read about John Inverdales comments.

I am in utter disbelief that after the Savile scandal, which exposed very clearly how an organisational culture in the BBC allowed the unacceptable to somehow become tolerated, Inverdale could make such comments. Is it common practice for sexist comments to be tolerated by the BBC? I hope not. Looks like the next scandal in the making, unless the BBC gets serious about changing their organisational culture.

Am I over reacting, maybe, but history is littered with individuals who have used stereotypes to persuade ‘big society’ that particular groups of individuals are somehow unworthy, even disgusting. They make derogatory comments about people they do not know because of some aspect of their biological make up, their parentage or lifestyle choices. This is dangerous given the current climate with a government keen on divisive policies that likes to categorise people into the ‘deserving’ and ‘undeserving’.

From this perspective the ‘little platoons’ suddenly feel oppressive, and likely to increase existing divisions in society. You just have to hope you end up in the ‘right’ platoon I guess?