Archive for November, 2011

Time to go

Tuesday, November 29th, 2011

Kay Sheldon’s comments to the Mid Staffordshire Hospitals Enquiry about the competency of the CQC’s leadership has surely signalled the death knell for the watchdog’s top team. As a fellow board member, her damning indictment of the CQC’s current culture, lack of strategic direction and inadequate training will put both Cynthia Bower and Dame Jo Williams’s positions under intolerable pressure.

In other testimonies at the same enquiry current CQC inspectors have described how their training and preparation for the job of inspecting standards in the NHS and care homes was laughably bad, and that many felt their redeployment to processing CQC applications was a very poor use of their time. Despite the rest of the CQC’s Board supporting the current leadership, the groundswell of opinion that this enquiry is now uncovering proves that something is very wrong indeed at the CQC. Further enquiries by the Department of Health, National Audit Office and Commons Public Accounts Committee – prompted by a series of criticisms of the organisation’s ability to do its job, may prove to be its final undoing.

In truth, few tears will be shed, as many have felt that the CQC is a bloated and flat-footed organisation, ill-suited to the task it has been given. No one doubts the need for rigorous inspections for all aspects of care in the UK, it is just that few think the CQC is the body to do it.


The thin end of the wedge

Monday, November 28th, 2011

For anyone with some experience of poor care on an NHS ward, or who has read the numerous stories of patients badly treated by over-worked or harassed nursing and care teams, yesteday’s revelation in the Sunday Times that people are now employing private nurses to look after them on NHS wards will seem understandable.

Although the practice of employing private nurses, often at around £200 per day, is not that widespread yet, the article suggested that the Patients Association believed that many NHS nurses welcomed these privately-funded nurses onto the wards as it helped ease their workload. That may be true, and there certainly can be no doubt that the intensive supervision that those with private nurses receive will certainly help to identify and ameliorate any post or pre-operative complications. The mantra of choice and patient-centered care has been at the heart of government health policy for the last 10 years, but why does the idea of people employing their own nurses on NHS wards seem so strange?

The first reason is a practical one. How can care effectively be organised so that the dividing lines between what the NHS nurses and private nurses do is clear to all? Would the private nurse step in if he or she saw another patient suffering on a ward and there was no immediate NHS nursing assistance available? There is also the insurance ramifications and certainly the experience of Prestige Nursing and Care with some NHS Trusts in Bristol is that they simply do not countenance this type of arrangement for that very reason.

Then one has to consider the morale of both the NHS nurses and patients on wards where these private nurses go into work. With an Orwellian twist it now seems that all patients are equal, except that some are more equal than others. This has always been true when you consider private hospitals and clinics and even private wards within NHS Trusts, but such encroachment into your common or garden NHS ward sends dangerous signals to both patients and nurses alike. On a larger scale it also calls into question how holistic the care the NHS gives can be. If patients are effectively voting with their wallets by saying they are happy to have the more acute clinical procedures undertaken with the NHS but do not trust it to provide effective after-care, you are faced with the very real danger of fragmentation of many services which themselves rely on an holistic approach.

So how has it come to this? Those with means have always had the opportunity to choose additional care if they so wanted, but the NHS has largely remained sacrosanct. The debate must now move on to address two key questions, both of which have been asked many times throughout this year. The first concerns the role of acute hospitals in a modern 21st century healthcare system and whether there are other options best suited to treating the elderly or those with long term ocnditions. The other question relates to nurse training, and whether the current system is producing those with the right skills and attitude to flourish in the role. We can never be sure whether instances of poor care are because nurses are either unwilling or unable to provide the level of care they should all aspire to, but public perception seems to be favouring the former explanation at present.

The late Steve Jobs of Apple famously favoured closed systems over the open ones of Windows, because be wanted to control every aspect of the user experience without outside software or hardware developers becoming involved. He felt that this control delivered much higher levels of user satisfaction and reliability than his rival Windows, which was put onto any PC that wanted it. The analogy  is certainly true here, the traditionally closed system of the NHS ward is in danger of opening up to outside parties and in doing so becoming merely a platform where disparate parties co-ordinate to deliver care. Although agencies like Prestige Nursing and Care do benefit from the demand from private nurses going into hospital wards, I still favour the good old-fashioned closed system of the NHS. What Apple did to ensure this type of system remained popular was to relentlessly innovate, what the NHS must do now to stop this becoming the thin end of the wedge is to follow suit, starting with how it organises and delivers nursing care.

Too little, too late

Wednesday, November 23rd, 2011

A few days before the Equality and Human Rights Commission publishes what is widely expected to be a damning report into the UK’s Homecare market, the CQC has decided to get its retaliation in early by announcing Homecare inspections to start by April next year. Unfortunately in doing so, it has turned what is a welcome development into what now looks like too little, too late.

Up until a few years ago the Care Quality Commission regularly conducted inspections on Homecare providers, but as the remit of the watchdog grew these became the exception rather than the norm. This time however there will be other organisations involved, namely the UKHCA, Age UK and the EHRC itself. The previous system relied on a series of stars, which indicated how good or bad the level of service from a provider was. Although it often failed to measure many of the nuances involved in Homecare and was very much a tick box exercise, it did engender a focus on delivering what the CQC believed was the correct recipe for good quality Homecare and that in itself was an achievement. The number of stars you were awarded became important, both commercially and morally, and poorer quality agencies suffered in their pocket if they were unable to increase their star rating. Yet whilst it was a laudable attempt to improve standards and provide a quick and easy way to rate the quality of a provider, particularly for those interested in organising Homecare, it suffered as all ratings systems do with a focus on the wrong areas, so much so that a 1 star agency would not be demonstrably worse than a 3 star agency.

The idea of transparency and greater regulation within the Homecare sector has a great deal of resonance though and companies like Prestige Nursing + Care would welcome it. What is needed this time is a more sensitive measure of how an agency delivers care, based primarily on feedback from those on the receiving end. Naming and shaming poor providers, including those in-house teams with local authorities, is the only way to ensure that standards rise and that poor care providers are forced out

One last point. The BBC reports that the CQC has pledged to report on 250 Homecare providers by April. Given that there are over 4,000 providers in the UK at present this starkly illustrates the scale of the task.

Let battle commence

Monday, November 14th, 2011

What happens when an irresistible force meets an immoveable object? A trip to the courts it would seem, as yet another Council’s plans to reduce its adult social care budgets are deemed unlawful by the High Court. Late last week a judge ruled that the Isle of Wight Council’s plans to reduce its adult social care budget were unlawful. This has eerie similarities to a case earlier this year when a judge ruled that Birmingham Council’s plans to reduce care for the disabled was also unlawful, and to one where Sefton Council were asked to rethink a freeze in fees it imposed on residential care providers.

Is this is the start of a new battlefront against local council cuts or is it a temporary pause in the inevitable as Councils attempt the unenviable task of trying to juggle an ever increasing demand for care with a rapidly shrinking budget? I fear it is the latter, as close scrutiny of the ruling suggests that the judges overturned the Isle of Wight Council’s ruling not because of some moral imperative, but because the Council did not follow it’s own internal guidance. Looking at the judgement one can see how the Council redrew the funding eligibility criteria to critical and substantial with a high risk of being unable to remain at home, but failed to consider the practical implications of this on the people receiving the care. Our own research on funding criteria for councils revealed a postcode lottery in care, with funding levels varying massively between councils only a few short miles away.

So as some commentators are already suggesting, this ruling may simply delay the inevitable and at some cost to the taxpayer as judges are asked to rule on an increasing number of proposed cuts to care. There will be many more of these battles to come, as people fight to protect their proportion of  shrinking care budgets across the UK. Most worryingly, once Councils start ticking all the legal boxes, there may be little anyone can do to reverse this trend.

Whose responsibility?

Tuesday, November 8th, 2011

Recent evidence that the Government is considering forcing the elderly to release equity in their homes to help fund domiciliary care reflects the growing crisis at the heart of elderly care in the UK. In simple terms the problem is one of money, or the lack of £1.2 Billion of it by 2014 to be more precise. Yet it would be wrong to define the terms of the debate around care solely in terms of money, despite successive Governments’ attempts to do just this.

The political posturing appears to have started already, so endangering the real possibility of cross-party concensus on the funding and delivery of elderly care. Messrs Burnham and Lansley have apparently fallen out over the latter’s alleged lack of discretion about similar talks when he was the Health shadow and not Mr Burnham. We shouldn’t be surprised at this – healthcare will always be a political football given the proportion of GDP it swallows annually. yet the size of the budget and who pays or doesn’t pay only masks the real question which is who is responsible for care? This may seem like an obvious question, but in the arena of long term care the whole issue of collective versus individual responsibility becomes particularly relevant. Should the state take full responsibility for the funding and delivery of care to the elderly, as is the case with the NHS on the delivery of acute care? Or should it be an individual’s own responsibility to provide for themselves in later life, just as this generation are being urged to do over pensions.

Andrew Dilnot’s report earlier this year attempted to put a figure on the funding of care, and to start drawing clearer lines between what the state and the individual should be responsible for. There is agreement that the NHS is not the best vehicle for elderly care outside of treating acute conditions, but the financial black hole at the heart of councils’social care budgets threatens to remove the safety net people currently enjoy as they are cared for in the community. Once again there is general acknowledgement that the UK’s demographic profile means that this issue will only become more acute as the number of people over 70 continues its inexorable rise upwards, but the need to act is now becoming critical.

The Government’s role is to clearly define the line of responsibility between te state and the individual when it comes to care and to communicate that message consistently and vigorously. They also need to bring the financial services community into the fold so that there are a far greater number of long term savings and insurance plans to help people save and pay for care in the future. There is certainly a conspicuous absence of these at present, robbing people of the ability to meaningfully pay for care (if that is what is decided) in the future. Next year’s White Paper on Social Care must address these issues and reflect the reality that whilst the funding of the care is obviously critical; the planning, choice and delivery of such care also have