28 November 2012, Jeremy Hunt, Kings Fund – Quality of Care
This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Our health and social care system faces many challenges and we rightly have lively political debates about all aspects of health policy. But…
Our health and social care system faces many challenges and we rightly have lively political debates about all aspects of health policy.
But sometimes problems are so deep-seated that when they surface no one really believes they can be solved. Or even worse, we stop noticing these problems because they have become so much part of the fabric.
And then you have to defeat the defeatism as well as dealing with the issue itself.
1. The normalisation of cruelty
Today I want to talk about one such problem, perhaps the biggest problem of all facing the NHS.
The crisis in standards of care that exist in parts of the health and social care system.
Just look at what has come to light in the last few years:
• Patients left to lie in their own excrement in Stafford Hospital, with members of the public taking soiled sheets home to wash because they didn’t believe the hospital would do it.
• The man with dementia who was supposed to be monitored every 15 minutes who managed to leave a Pontypool hospital and drown;
• The residents kicked, punched, humiliated, dragged by their hair, forced through cold showers at Winterbourne View.
• The elderly woman with dementia repeatedly punched and slapped at Ash Court care home.
• The cancer patient at St George’s, Tooting, who lost a third of his body fluid, desperately ringing the police for help, because staff didn’t listen or check his medical records.
Isolated incidents? Well, sadly not. But as well as the depressing regularity of these stories, the most worrying thing is the fact that in certain institutions this kind of care seems to have become “normal.”
In places that should be devoted to patients, where compassion should be uppermost, we find its very opposite: a coldness, resentment, indifference, even contempt.
Go deeper, and look at the worst cases - like Mid-Staffs and Winterbourne View - then there is something even darker. A kind of normalisation of cruelty, where the unacceptable is legitimised and the callous becomes mundane.
There’s a simple test every layer of the health and social care system should be applying. And that is to ask: is this the care I would wish for myself, or for a loved-one?
Care as you would wish to be cared for. In Winterbourne, in mid-Staffs, in Pontypool, Tooting, Ash Court, this principle was utterly and horribly abandoned.
2. Betrayal of the majority
It’s really important to stress that this is not the picture in most of the NHS or social care system. But the outstanding care that you see in so many institutions - even those under severe financial pressure - shows why we must face these cases with anger, and not with resignation.
Because they betray the outstanding men and woman who have given their lives to the NHS and caring professions - and who make this job for me the biggest privilege of my life.
People like the nurse I met at St Thomas’ who was looking after a terminally-ill patient who had lost touch with his family 20 years earlier. This nurse looked the family up on Google and arranged to fly the patient back to Ireland so he could spend his last two weeks reunited with them.
The Care Home Manager at Rathmore House in Swiss Cottage, caring for people with advanced dementia. The manager who lives every day just to try to get a smile out of patients with advanced dementia even though, she says, they won’t remember the next day.
The GP who works 15 hour days trying to work out care plans to stop her frail elderly patients being unnecessarily admitted to A & E.
So many people represent NHS values at their finest. In every fibre of their body, they care as they’d wish to be cared for. And they are the ones most let down when we fail to tackle poor care head on.
3. Why good care matters
Nor should we make a false dichotomy between good treatment and good care. The King’s Fund, generously hosting us today, has always championed a rigorous evidence-based approach to healthcare issues. They know good care directly supports good outcomes.
- Veena Raleigh’s work for the Kings Fund this month showed the link between good care and good outcomes across GP practices, what she described as a “strong association” between patient satisfaction and clinical performance on the Quality and Outcomes Framework.
- Consistent with this, a Lancet study in 2001 concluded that doctors who adopt a warm, friendly, and reassuring manner are more effective than those who don’t.
- And the Commission on Improving Dignity in Care has shown that when elderly people are not treated with compassion and respect this can affect their recovery, even if the clinical treatment itself is excellent.
The argument is clear: good care means healthier patients and stronger balance sheets - yet too often the message isn’t hitting home.
4. Stronger accountability from managers
So what are the solutions?
Let’s start at the top. We urgently need to strengthen corporate and managerial accountability for the care provided.
Yet too often managers have seen their priority as financial or clinical outputs. Incentives in the system have driven people to focus on quantitative input measures rather than the basic human right to be looked after with dignity and respect.
Most managers get this - indeed their passion for the highest standards of care is why they have chosen to become managers in the NHS or care sector. But too many do not. Buried in spreadsheets, they become blind to the realities of what’s happening day-on-day inside their organisations.
It’s this whole culture of ticking the box, but missing the point which is what we have to put right.
And we have to be much clearer about the consequences that will follow if leaders fail to lead, and fail to drive high quality care throughout the organisation.
Just as a manager wouldn’t expect to keep their job if they lost control of finances, why should they if they lose control of care?
The same is true for owners and Boards of companies. Accountability must stretch to the top. And when we publish our response to Winterbourne View we will set out in detail how we intend to achieve this.
5. Greater transparency
Secondly, we need to know much more quickly where the problems are.
Next year we will roll out the “friends and family” test across the NHS. For the first time hospital users will be asked if they would recommend the care they received to a friend or close member of their family. NHS staff will also continue to be asked anonymously whether they would recommend their organisation to their own families.
This is the closest measure we can get to “care as you would wish to be cared for”. And we will publish the results.
So that’s a very important first step. But we need to do much more.
As an MP I know how well each school in my constituency is doing thanks to independent and thorough Ofsted inspections. But I do not know the same about hospitals and care homes.
Given the scale of the problems we’re uncovering, it’s now clear we need to have a proper independent ratings system. It is not acceptable to deprive the public of the vital information they need, or remove the pressure for constant, relentless improvement in standards.
I am not advocating a return to the old ‘star ratings’ but the principle that there should be an easy to understand, independent and expert assessment of how well somewhere is doing relative to its peers must be right.
So this week I have asked for an independent study to be done as to how this might be achieved in a way that does not increase bureaucracy.
I want to see a system that will provide - like Ofsted does for schools - clear, simple results that patients and the public can understand;
That will be - like Ofsted - an engine for improvement, driving organisations to excel rather than just cover the basics;
A system that gives greater certainty that poor care gets spotted and addressed before standards collapse.
When I receive the results of that study, I will consider it carefully alongside the Mid Staffs report from Robert Francis. I will then announce to Parliament how we intend to resolve this issue.
6. Better training
The final and equally important side to all of this is staff development. The King’s Fund and many others have shown that staff who feel engaged and valued in an open and supportive working environment deliver better care and support for patients.
And yet in these highly charged, busy, stressful environments, too many are left ‘not waving but drowning’, cut adrift from the help they need to do their jobs well.
And again the consequences can be profound. One well-respected study from 2006 found that hospitals with better supported staff provided better care and had lower mortality rates.
An incredibly powerful finding, which shows that a lack of staff support, ultimately impacts on patients’ survival chances.
Staff in healthy organisational cultures, given the space to process the difficult emotions that caring throws up, will provide better, safer care.
So what is in train to support them?
New standards for senior managers issued by the Council for Healthcare Regulatory Excellence - echoing the need for respect, compassion and care for patients at the heart of leadership and governance.
A leadership qualities framework for adult social care published by my department which will do a similar job for care organisations
Next week, we have the launch of the new Vision for Nurses, midwives and care staff following the £40m in leadership development programmes for nurses, midwives and registered care home managers announced by the Prime Minister in October.
Next month - the establishment of the Professional Standards Authority to make sure the professional regulators do their jobs and protect the public effectively; and the beginning of a new era of medical revalidation, making our systems the best in the world for supporting doctors and ensuring standards;
And then early next year - the first ever national set of standards and a code of conduct of conduct for health and social care support workers are published.
All of this is underpinned by:
- an NHS Mandate explicitly saying quality of care should get the same attention as quality of treatment, and emphasising the pledges to staff in the NHS Constitution
- And a new organisation - Health Education England - entirely focused on the education, training and development of the health workforce.
7. Addressing the challenges
So a lot is happening. Of course there will be those looking at this and saying “Can we really do it?”; “Is it realistic to expect organisations to invest more in people and in the quality of care at a time when money is so tight?”
There are indeed financial pressures in a period of rising demand and flat budgets. But as the CQC said last week, most Trusts and care homes deliver excellent care despite a tough financial environment. So there is absolutely no excuse for those that do not.
But it is also wrong to equate better care with more money. More accurate would be to say what today’s Kings Fund report states plainly: it is bad care that costs more - including the £1.4 billion spent on unnecessary emergency admissions.
What about staffing levels and in particular the reduction in nursing numbers?
As people stay in hospital for shorter periods, and indeed 80% of hospital appointments now do not involve an overnight stay, patterns of care change.
But if quality of care is really to be as important as quality of treatment we should be clear that changes to workforce numbers must not compromise the care provided.
8. Conclusion: widening the circle of compassion
In surveying the broad sweep of the universe, Einstein once spoke of people shedding their individual perspectives and ‘widening the circle of compassion’ if humanity was to progress.
In the health and social care universe, which can be every bit as unpredictable and complex as the world around it, the same message rings true.
In its sixty-fifth year, pitted against its biggest ever challenges, we need an NHS that is always searching, always improving, always striving to do more for patients.
We take for granted improvements in medicine, in surgery, indeed in life expectancy. But none of this is real progress unless we are also treating our citizens with the dignity and respect they deserve.
Widening the circle of compassion. Denormalising the unacceptable in those rarer cases. And living the principle of care as you would wish to be cared for everywhere.
The founding ideals of the NHS expect no less.