No one ever said the NHS was perfect... except successive governments. Unfortunately, the author of this scholarly and well-researched book has the evidence to show that systemic failures within our health services are responsible for appalling lapses in the care of vulnerable patients.
Detailing numerous abuses and neglect, this book is the antidote to institutional spin and should be required reading for every NHS manager and health professional.
How We Treat the Sick: Neglect and Abuse in Our Health Services By: Michael Mandelstam
When I chose this book to review I saw that no one else had. That in itself put me off a little as I thought perhaps they like me were a little daunted by the title and subject. I thought however that someone ought to read it and give a reveiw of it.
The author says this is not about the NHS but as far as I can tell that is just about all it is about. He says he wants to set out the problems within the healthcare service in a non anecdotal way, as the converse is often the case, and that it is easier to ignore the odd story of woe than the overwhelming evidence of woeful story after another. But he doesn't give you any statistics. Therein the book falls down. I cannot take a book seriously whose author says he wants to prove how bad the UK healthcare system is and then fails to give any form of statistical analysis. I want to know how many people were treated without reported problems against those who had reported problems. That is the ONLY way you get away from being anecdotal.
It is a real shame because there is a lot of really good information in this book, but it could have been a lot better.
Where its strengths lie are in the breakdowns of the problems described, the mechanisms that may have caused them, and the way that hospitals are run and managed, including the bed management computer systems, and I do recommend it for explaining those things and helping teach me how hospitals are run.
The stories from people who had experienced or witnessed problems were verbatim, spelling mistakes and all; it was really enlightening but of course depressing. I did feel for the people concerned. But I need to know how frequently this goes on, and if most people are treated well and some suffer, I know it is awful, but we cannot say for sure the whole thing is broken without giving some kind of data.
I am hopeful that the author will take this book further next time and actually look at the figures involved, because it is worth doing; this book, if indeed the healthcare service is very sick, needs the proper data analysis if it is to be taken seriously and if it is to escape from association with the word anecdotal.
This is a shocking book which makes no bones about the crap care which is dispensed to some of our most vulnerable people, particularly the elderly.
I have a long career as a nurse and would be ashamed to have had any involvement in the cases cited within this book.
If you are a student nurse, if you are a medical student, if you move patients from one area to another in fact if you meet patients in any way then this book is worth reading.
The book argues (well in my opinion) that the system plays a massive part in actually ignoring the basic needs of the very people it is supposed to be caring for. Structural changes to the NHS system, removing nurses from day to day care, selling off cleaning services to the lowest bidder, contracting outhave all played their part in contributing to declining standards.
Let's take it back to basics and ask "what do patients need"? Well in my opinion they need to be able to feel clean and have clean clothing and bedding, eat a reasonable diet with enough calories, sleep and get adequate rest and get to the toilet in adequate time and they need this with care, support and a smile. It's not rocket science and yet the NHS has lost sight of this with ever indepth policies which claim to meet patient need and yet doesn't.
I cannot stress enough IF YOU WORK FOR THE NHS THIS SHOULD BE ON YOUR READING LIST.
I would recommend this book.
The equivalent of a hand grenade going off in a tightly packed board room meeting. Naming and then detailing the trusts involved in the New Labour NHS National Strategy micro-managing their appearances. This involves adopting a cosy fuzzy picturesque brochured image to the outside world with glossy papers, obscure stats, self congratulatory commissioned glowing reports- The Power Pointers; anywhere but themselves to blame; sociopaths in suits.
Meanwhile in the real world families already suffering trauma during bereavement are left numbed shocked, traumatised by the poor standards of care for their elderly relatives. These older generations were those who were sons and daughters themselves, who fought and toiled throughout the century to be forgotten at the end.
When Money became god, those who struggled through the penury and world wars are left to lie in urine and feces. The 21stC sees itself as a progression from the 6thC Anglo Saxon world. In the 6thC kith and kin were THE important components of the social bond. Now ruptured it lies within the hospital system to ease the last moments. For many this is more trauma.
Mandelstam has dug deep into the mire, emerging with a geneology of catastrophic failure based on a series of small incidents. The problems are systemic, emanating from the very top, cascading downwards. All hierarchies represent the psychology of the leader. Blair and Brown chose their health deputies. Andy Burnham and the ones before, Frank Dobson, John Denham, Dawn Primarollo. All instigated a seeminglyly catastrophic reign of psychological unease onto their mannequins, known as psychological bullying. The supplicatnts then passed down the pressure onto those below. The effect of this close micro management was to stifle initiative and instigate pressure as a form of psychological terror. Targets became the main function of the job with nurses being forced to change their working activities from personal touch to the impersonal glare. Alienated work became the result as people hurried away from work to leave it to the next.
Whistleblowing became an excuse to demoralise workers further as the whole culture under NL was to erode any form of resistance under interminable paperwork, meetings and gloss.
Washing patients, assisting them with being fed and talking to them were secondary to all of these targets of waiting times. The end results of care were left unmonitored as the bereaved families, those who lacked the emotional energy were left with the end results, a dead body. Whilst they could vent their anger at the nurses no one would take them seriously after the event because they were so distraught. Besides how they could they bench mark their care? They would have to reveal the embarrassment of their indignity to others to ascertain the truth.
Behold a national NHS scandal was born emerging piecemeal through various "micro" scandals; Stoke Mandeville, Staffs, Grays and Thurrock, Lewisham, Basildon, Tunbridge Wells, Leicester, Tameside, North Tyneside, Bromley, Sutton and so on in the roll call of shame.
Within this morass the bugs blossomed as the bond structures within hospitals became fractured. Going that extra for patients was perceived as unnecessary to achieve the targets. The notion of alienation within work, when it is reduced to tedious functions was a product of those who were unaware what "empathy" means and its role within "care." One of the key fundamental problems within the current structures is those who bully rise to the top. By their very nature these are the people who have no empathy and therefore least able to understand the notion of "care." For them it is all about technique, as they project their "autism" onto the mass populace as a "norm."
Then what happened? Even when the Chief Execs were sacked as incompetent they re-emerged as consultants!!! They were better feather bedded than Premiership football managers. Incompetence could never be shaked because it was systemised.
This is a book for those who have been emotionally downtrodden, the brutalised, chastised and degraded to clasp open read weep and begin the fightback against these people who have robbed the vital moments of many peoples lives. They need to be pilloried for their incompetence and misdeeds so they never stand for any political party. The bureaucrats need to be chased out of their jobs so they land on the collective dungheap where their open wounds can fester and gain empathy through suffering.
They took one of the biggest injections of cash into health the country has ever seen and squandered the money on their "socially included" bean-feasts whilst letting the people who the service was built lie festering on trolleys.
It is a national travesty that not only afflicted the elderly. Look to the mentally ill and those with substance use issues for further evidence of New Labour incompetence.
Whilst the NHS is pulled apart in this book, the author makes no claims for private care as being better, more caring and able to fill the gaps. The whole rationale for the treatment of the elderly is akin to becoming as useful as Duracell battery than no longer lights a torch, due for the waste disposal unit. Private care intensifies the problem, one only has to look at the elderly care homes where old people are starved, spoken down to, denigrated and sometimes beaten. Private Care is even more brutal in this respect, if you have money then you receive care as long as the credit card pays, when there are no credits the gas flame goes out.
The remedy offered is more localised country hospitals and less bureaucratic health factories known as hospital trusts. Small is more beautiful when you know who is caring for you and they are integral to the local communities. This is a return to the old Anglo Saxon worlds of kith and kin. "Care" is undertaken by people you know not strangers having to reach targets. This is not care but the Ford production line of the 1920's (whatever happened to them) applied to hospitals.
Health is not just about technique and drug administration, it is about talk, touch and dignity. New Labour was the new effluence, the spiv with the Rolex and the Boss suit parading the corridors of power glancing in the mirror to catch a reflection. The narcissist gazing at whether it was all real or not. Totally divorced from the people who put them there, they set about like "Snowball" in Animal Farm to help themselves to the silver.
Despeakable; power pointers in suits- this book is the curse upon you!
on 1 May 2011
With the current controversy about reforming the way the NHS is organised, and how services are commissioned, it is all too easy to lose sight of the absolute bedrock on which patients' wellbeing depends - the care they receive day to day on the wards from nursing and medical staff. The book is an antedote to any tendency to complacency on that score.
The author in an article for 'The Guardian' maintains that bad practice 'is now a systemic blight, rather than local blemish'. He does not attribute this parlous state of affairs to staff who have 'discarded compassion and humanity', but points instead to inadequate staffing and too few beds - so that, as he puts it, 'exhaustion and demoralisation may be mistaken for indifference'.
His new book covers the vital basics of patient care - maintaining patients' dignity, helping them get to the toilet, keeping the environment clean and managing infection, & helping patients eat and drink.
Students of medicine and nursing, and those currently involved in the management and delivery of patient care in the NHS will find this book well worth reading. It is not an easy read - some of the case studies are very distressing - but the problems it sets out are too important to ignore.
It's tempting when you set out to make an exposé, whether television or literary, to go down the road of a rant and look at all the negatives. Mandelstam avoids this, but there is so much wrong with the UK's health system that it is very sad to read.
The other temptation is to set out all the problems and stop. Again, that doesn't happen here. The solutions are proposed clearly, even if their implementation is liable to be very difficult.
Every primary care trust and foundation trust should be issued with a copy and three weeks later tested on its contents to make sure they have read it. Copy to the health secretary while on the subject, as persistent meddling and suboptimal behaviour from the government increases the problem.
The truth hurts, but this book shines a light on the health sector and courageous action is the only way forward.
I can't think of anyone who wouldn't find this a difficult and troubling book to read.
In chapter after chapter we get details of the most horrific treatment of the vulnerable and elderly in NHS hospitals, from leaving the elderly in their own excrement and urine, to not feeding them or giving them anything to drink to keeping call buzzers out of reach and simply ignoring cries for help.
And these aren't just collected horror stories from a few people, repeated reports going back at least ten years have been saying the same thing - organisations such as Age UK regularly publish reports about this treatment, but nothing happens.
Nothing happens? Well, not quite, plenty of guidance happens. It seems the worse patients get treated, the more guidance gets issued, as if the problem was the staff didn't realise they were suppose to look after the patients and extra guidance will address that problem.
The start of chapter 6 has the following two quotes:
We respond with humanity and kindness to each person's pain, distress, anxiety or need. We search for things we can do, however small, to give comfort and relieve suffering... We do not wait to ask because we care. (NHS Constitution. Pledge by the NHS, 2010).
We got there about 10 o'clock and I could not believe my eyes. The door was wide open. There were people walking past. Mum was in bed with the cot sides up and she hadn't got a stitch of clothing on. I mean she would have been horrified. She was completely naked and if I said covered in faeces, she was. It was everywhere. It was in her hair, her eyes, her nails, her hands and all on the cot side, so she had obviously been trying to lift herself up or move about, because the bed was covered and it was literally everywhere and it was dried. It would have been there a long time, it wasn't new. (Mid Staffordshire NHS Foundation Trust: evidence to the independent enquiry, 2009).
Is it about money? There is a story on page 78 of a 93 year old woman who has been in hospital for two weeks and hadn't had a bath. She is getting smelly and grubby. A doctor comes to her, to offer her a surgical heart procedure. She replies "don't be silly young man, I have had a marvellous life and I don't want to be messed around with now. But what I would really like is a bath". She never did get the bath. How can the hospital afford to offer her heart surgery but can't give her a bath?
While it must seem strange to anyone that staff trained to care for the sick can behave in this manner, there seem to be some probable causes:
1. Understaffing - very often only a few members of staff have to look after a large number of patients, and clearly not everyone is going to get the time and attention needed. However of itself this isn't really a good explanation as to how people can get the appalling treatment detailed. At most, lack of staff would mean the care was poor or average rather than excellent, but the sheer cruelty of some behaviours can't be explained by lack of staff. One aspect of lack of staff that is important is that existing staff may end up working long hours, or working without a break, and this can affect the mental state of staff.
2. Demoralisation of staff. This adds to the picture. It seems often staff are not allowed to act on their own initiative, they may be disciplined for doing something that appears to be "common sense" and increasingly lose their ability to have confidence in their own judgement. They get into a state where the world seems crazy and no one cares, so they just do what they are told and don't question it. This is also related to chasing targets - sometimes meeting a target is more important than looking after a patient. This is essentially a problem of the culture of the NHS.
3. Bullying in the workplace. This is related to demoralisation: it seems too often managers and senior staff bully junior members, leading to high levels of stress, depression and anxiety, which in turn can result in inhuman behaviour towards patients.
4. Lack of sleep. Often NHS shift patterns are subject to regular changes. A member of staff may work one shift one week, then a different shift the next week, and a different shift again the third week. There is no regularity to shift patterns, instead of a staff member regularly working nights, they may be on nights one week and a day shift the next. Sometimes shifts may clash so the staff member only gets a few hours break between one shift ending and another one starting.
All of these factors point to poor management in the NHS and the necessity of a change of culture where the staff are given more control over how they work. Modern industry innovates by giving staff maximum flexibility to get the job done, and does not micro-manage how tasks should be performed. The NHS needs someone to make these fundamental changes, until that happens the problems detailed in this book are going to continue.
The National Health Service is the jewel in the crown of social policy and the welfare state. All parties claim their opponents are seeking to destroy it although many politicians do not use its service and rely on private medical plans. New Labour, in particular, was scathing in its attacks on Conservative policies in the 1990's for an "internal market" which they claimed was leading to the privatisation of the NHS. At the outset of Blair's first administration in 1997, a White Paper proposed replacing the internal market with integrated care, saving £1 billion in adminstrative costs which would be "put into frontline care" and underwritten by guaranteed standards of care. It never happened, access to the NHS was no easier or swifter than it had been before. At the outset of the second Blair administration New Labour embraced the internal market, fundholding was introduced under a different name, service standards were tightened, targets became an integral part of the drive for financial control, while Modern Medical Centres were introduced to decrease the number of hours doctors had to work before gaining higher medical status.
The changes proved to be cosmetic rather than real, particularly in the area of long term care. The picture Michael Mandelstam portrays is a sad and sorry one of patient abuse and the failure of the NHS to maintain the principle laid down by Florence Nightingdale 150 years ago that "the very first requirement in a hospital is that it should do the sick no harm." He relates a narrative which shows an absence of basic nursing care, with staff failing to permit patients any dignity in their declining years. This appalling situation was publicised by Martin Bright of the Observer and Lord Winston, both of whom had personal knowledge of inadequate treatment doled out to close relatives. In 2001 the National Service Framework for Older People was issued and accusations of the mal-treatment of patients was angrily dismissed by Blair himself. However, evidence to the contrary came with with reports by the Healthcare Commission of deficiences in care at Stoke Mandeville and at hospitals adminstered by the Maidstone and Tunbridge Wells NHS Trust. Martin Bright wrote about the absence of respect and dignity in the treatment of the elderly. A decade earlier he did not blame the government for such absence, in 2008 he did.
New hospitals were built under the private finance initative which saddled NHS Trusts with heavy repayment debts. To meet these repayments Trusts closed wards, shed jobs and reduced the number of available beds in a manner reminiscent of "The Compassionate Society" in "Yes, Minister." Patients tended to be obstacles to administrative efficiency and should be dispensed with. However, unlike the fictional hospital which had an abundance of staff and no patients, health care of the elderly has had a lack of staff, an abundance of neglect, an absence of basic care and bad practice in distributing drugs. Frankly, the top heavy NHS management did not care for patients' welfare only the cost of care provision. These characteristics were uncovered by reports from the Care Quality Commisssion following investigations into unusually high mortality rates. In March 2009 the Healthcare Commission published a report into the severe failings in emergency care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2008." The Health Minister, Andy Burnham, established an independent enquiry headed by Robert Francis QC. Francis received almost 1000 submissions from relatives of elderly patients but very little input from the Trust staff.
Francis took as his benchmark the 2003 Department of Health document "The Essence of Care" which identified specific areas for patient care. They were continence and bladder and bowel care, safety, personal and oral hygiene, nutrition and hydration, pressure area care, cleanliness and infection control, privacy and dignity, record keeping, diagnosis and treatment, communication and discharge management. Patients with bladder and bowel problems were frequently ignored and not provided with assistance getting to the toilet by staff who appeared uncaring and unsympathetic, sometimes leaving patients sitting in their own urine and faeces. Patients with specific problems were often ignored and, in some cases, relatives' offers of help were rejected as being against Health and Safety rules!!!! Pressure sores were so widespread that they indicated a systemic failure of care and poor nursing training. Francis concluded that the Trust had misintrepeted government targets and, by making those targets sackable offences, placed intolerable stress on nursing staff. Doctors who raised concerns about the standard of patient care were told nothing would be done because of wider issues and financial considerations. Similarly when staff raised issues they were ignored by, or not related, to the management team.
Bad management practice facilitated bad clinical practice. The Trust management attempted to absolve itself by claiming its role was a strategic not an operational one. While Francis accepted this was theoretically right he stated it provided, "no excuse for not delving into the operational during times when it was known that there were no governance structures in place or only developing ones. It should have been realised that until reorganisation was embedded and proved to be effective, it could not be relied on exclusively. It was necessary for directors to roll up their sleeves and see for themselves what was actually happening" Francis reported early in 2010 and following the General Election Andrew Lansley appointed Francis to head a public enquiry, " into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Stafforshire NHS Trust" which is currently taking evidence. Whether it will lead to change is moot.
None of this will stop politicians claiming they are defending the NHS on which Blair inflicted targets at the expense of service and Brown provided money beyond the financial competence of Trusts to allocate it efficiency. The NHS deserves better than to be a convenient slogan in the political battle. Five stars.
Objectivity is a strange thing, no no, hang on I am not saying the author is lacking in objectivity, well maybe I am a bit, he certainly pulls at the heart strings, and whilst doing so does make any of his arguments (facts?) irrelevant, it does, for me, tinge them with just a little bit of subjectivity. He relies on anecdotes at times, he postulates, extrapolates and surmises.
Look, there is no doubt in my mind that the basic premise of this book is sound . I work in the NHS, I come face to face on a daily basis with the issues he describes, and sometimes see the results of the plethora of targets and regulations with which we have to work, its not fun I can tell you.
And yes I know Mr Mandelston worked in the same environment too (he now delivers training on how to ameliorate the consequences of government edicts),so to a large degree he ought to know what he is writing about.
But I dont think legal action as he suggests will necessarily change things, caving in to someone suing the NHS, is always going to be cheaper than the wholesale change needed.
But, he misses a point, there is no such thing as the NHS( in my view one of the biggest cons currently perpetrated by govt) as it was originally established. It mostly run by trusts, who are financially independant of govt in the decisions they make. These trusts establish themselves by paring down their services so they can effectively become independant quangos and run the service with minimal intervention from govt. Check out who runs your local nhs services if you wish and see for yourself.
It is a reasonably important book that could have gone much further, but nevertheless its quite a gruesome read