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It’s an age old story

2011 October 14
by Paul Vallely

The woman in the bed opposite was a pest. So the nurses thought. You could see why. She was in her Eighties and had some form of dementia. She pushed the button to call for help every five minutes. After days of the continual buzzing of her ceaseless summons the nurses moved the button out of her reach. But they popped in to check on her every 20 minutes or so. Who could blame them?

So there was no-one there when the old lady finally admitted a ghastly gurgle which proved to be her death rattle. One of the other patients pushed their buzzer. A nurse came fairly swiftly but the old woman was dead.

Yesterday’s report from the Care Quality Commission into the care of the elderly in Britain’s hospitals has far worse stories to tell than that. One incontinent patient was left unwashed despite asking for help. Patients were without intravenous fluids. Call bells were put out of patients’ reach, or not answered soon enough. Staff spoke to patients in a dismissive or disrespectful way. The elderly were not given the help they needed to eat.

After unannounced visits to 100 National Health Service hospitals it found that less than half feed old people properly or treat them with compassion or dignity. One in three hospitals needed to make improvements in one or both areas. One in five were so bad they were actually breaking the law in their treatment of the elderly.

I have spent a lot of time in hospitals over the past three months since my mother, who is 84, has been admitted no fewer than four times, for up to three weeks at a time. So I can add a couple of stories to the Care Quality Commission report. In addition to the old woman who couldn’t press her buzzer as she died there was a student doctor who came to see an old woman who had been without food for six hours during admission and asked her the same series of questions which the registrar has already asked. The student persisted despite the woman’s best efforts to cram a cheese sandwich into her mouth as she answered.

“Shall I come back when you’ve eaten,” she eventually asked, extremely belatedly, as the old lady did valiant battle with the bread, her false teeth and the duplicate Q&A. The old woman nodded.

Yet I have only those two stories. News is about the unusual, dramatic or shocking. So they fit the requisite template. And yet the overriding impression I have after my prolonged recent exposure to the NHS tells the exact opposite story. The numerous nurses, ancillary staff and doctors I have encountered have been models of good   practice – varying from the professionally caring to the deeply personally kind.

They also displayed tremendous patience, in the face of circumstances which would be immensely trying – old women who called constantly round the clock, moaning, whimpering or, in the case of one, wailing like a banshee. Then there was an old woman called Gladys, who always wore a bright pink nightie, and who shuffled round the ward, following the staff nurse like a devoted or over-anxious puppy, never letting the nurse move more than a few steps away.

There were a couple of nurses over the months who were grumpy or gruff but even they were not patronising or condescending. The overwhelming sense my family came away with was one of a profession where  extraordinary effort and compassion were the norm. Reading the CQC report yesterday filled me with sadness at the impact its words would have had on those dedicated hospital staff. The blow to their morale must have been shattering.

To say that is not to minimise the distress of those who have suffered at the hands of those members of the profession form whom nursing is clearly just a wearisome  job rather than a vocation. It is merely to note that the NHS sees over a million people every 36 hours and, in the words of a Health Ombusdsman’s report from February this year “the overwhelming majority say they receive good care”.

But yesterday’s report throws up a more interesting question. Health service unions were quick to defend their members by pointing to tightened budgets, overworked staff and burdensome paperwork. There are many who think that the Coalition government’s controversial reforms of the NHS may make things worse rather than better. The government has told all hospitals to prepare to become foundation trusts. But at least 20 are in such dire straights that they are no longer financially or clinically viable, the National Audit Office said this week. It is alarming to read that 40 years ago the NHS had just 500 senior managers and has 70,000 today.

And yet this goes beyond finances. The CQC report said: “Having plenty of staff does not guarantee good care – inspectors saw unacceptable care on well-staffed wards, and excellent care on understaffed ones”.

The key determinant is the attitude of staff – and the tone here is set by the person who is now called the “ward manager” but who once would have been called the Sister. Some of these are warm and friendly. Others brisk and efficient. But none of the dozen or so I have encountered recently would, thankfully, have been prepared to tolerate the unpleasant attitudes the CQC reports when an old woman awaiting discharged asked a nurse to ring her daughter only to be told “That’s not my job”. We had several unsolicited calls from nurses and even consultants.

One of the key tasks of a ward manager is to set priorities. Clearly medical emergencies come first but incontinent patients who soiled themselves were ministered to swiftly on the wards where I have sat for countless hours recently. But good care goes beyond a hierarchy of need.

Kindness and compassion cost nothing. If a ward manager looks around her and sees people rather than beds that makes a key difference. Why some people are compassionate and others insensitive is a question which goes to the heart of human nature. But if we are seeing a decline in caring that might say something about our wider society and a culture in which impatience and frustration are more generally on the rise.

There are other issues which are more readily addressed. Food is one such. Our hospitals are filled with old people who are physically unable, or psychologically disinclined, to eat the hospital meals that are put before them. Malnourishment through lack of attention is one of the most shocking parts of the CQC report. Certainly it is common to see food being cleared away untouched after sitting by a bedside until it has gone cold. One hospital food server told me that around a quarter of all the meals that were made in her Manchester hospital were uneaten. One in 12 hospital meals is returned uneaten, costing more than £22 million a year, according to national NHS figures.

There are a number of issues here. Hospital food is more often than not distinctly unappetising if not utterly unpalatable. Chefs like Jamie Oliver and James Martin seem to have had little real impact in their campaigning. That is unsurprising where food budgets can be as low as £2.93 per patient a day. There are some things that money does buy.

Food, like sleep, is nature’s medicine and hospital doctors and managers should pay more attention to that. The CQC report spoke of doctors who resorted to writing prescriptions for drinking water to ensure patients had enough. Perhaps they should do the same with decent food.

But quality will make no difference to those old people who are too frail to feed themselves. It is unrealistic to expect a small nursing staff to be able to do that. Wards have a few ancillaries but nowhere near enough. If Britain’s old constitute a betrayed generation so too does a young one which has been educated into unemployment. Jobs or some form of national community service could bring together old and young in a way which would give purpose to both extremes.

There are those old people who chose not to eat as a way of easing themselves into death. “I’m 91 you know,” the old lady munching her sandwich shouted at the departing student doctor, by way of a parting shot. “I’m on the way out.”

She was joking. But Peggy, in the bed next to my mother, after a fortnight in a hospital bed, decided at the age of 94 that she would never be able to go home to live on her own. She had a few visitors, but she talked to them without much engagement. Then she began not to eat, and then to refuse her  medicine. She faded away within a week, nursed with great tenderness as she declined.

Old people, like the rest of us, make their decisions. But, unlike younger generations, they need assistance to carry them through. This is not some geriatric backwater. Older people account for three quarters of all NHS patients. And the elderly population is set to double over the next 25 years.

Treating the services, like podiatry, that older people particularly need as Cinderella areas requiring meagre funding must be a thing of that past. So too must be the idea that older patients, with their frailty and dementias, can be treated as bundles of conditions rather than as people. “The whole hospital is a geriatric ward,” one doctor said. Old people need our best doctors, our brightest medical students and our kindest nurses. They deserve nothing less. 

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