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This review is from: How We Treat the Sick: Neglect and Abuse in Our Health Services (Paperback)
Customer review from the Amazon Vine Programme (What's this?)
I was interested in this book partly because of the experience over a period of about ten years of watching how my parents were treated in several hospitals and my own experience as an inpatient. I was staggered by the enormous variation in the quality of care in these various hospitals. Mandelstam's description of what has gone on makes grim reading. He describes hospitals failing to deliver basic care - hydration, nutrition, hygiene, infection control, dignity of the patient, failing to prevent bed sores. It should be shocking but it didn't surprise me.
Mandelstam's thesis is that these are systemic problems emanating from the top rather than local failures. Up to a point that may be true, but he didn't wholly convince me. To blame all the failings on government does not square with variations in care between hospitals, including hospitals within the same trust, nor between different wards in the same hospital, or indeed different shifts on the same wards. As both a patient and a relative of patients I have witnessed variations that appear to be based on the attitude of staff. Sadly some of what I have seen has seriously diminished my faith in the nursing profession, notwithstanding that I have come across truly wonderful nurses too.
Undoubtedly some of the poor basic nursing practice reflects staff shortages and pressure on beds, and some will be attributable to lowered morale, but that cannot explain all the poor practice. He quotes nurses or former nurses being appalled by the 'care' provided by other nurses. Mandelstam accepts this: "Despite this bond between too few nurses and decent care, it is not just about numbers. Competence and attitude clearly matter." However, he tries to lay the blame for this at a higher level: "Furthermore, whilst there will always be some staff with the wrong attitude, they and others will be tacitly encouraged in the wrong way if they receive an unspoken message from senior management that basic care doesn't matter, and that other things count for more." Sorry - but in my view this lets errant staff off too easily. Staff know right from wrong - basic care & dignity are not the stuff of rocket science. You don't need to be a medical professional to know that people will die if they don't receive adequate food and drink. As professionals they need to stand up for what is right, blow the whistle where necessary. If they don't, they risk being held accountable for the care provided even if the real responsibility lies elsewhere.
The author quotes a relative of a patient at the Royal Liverpool University Hospital who said "...I do not believe that nurses today actually care about people, and I do not know why they take up the profession." My own experiences bear out that view. As an outsider, it strikes me that something is going wrong with the recruitment and training of nurses. Somehow in the effort to increase the standing of the profession something has been lost, but this isn't even touched on in the book.
Mandelstam recommends that the regulators and professional bodies develop more backbone and that staff too may have to become more assertive, if only to protect themselves. He rightly refers to the dreadful response of the Nursing and Midwifery Council in seeking to strike off a nurse who blew the whistle on appalling care - this was only revoked after a public outcry. He notes that very few have been struck off their professional registers. In relation to the regulators, there is a major flaw in the system in that much of the assessment is conducted by the trusts. No doubt this explains the huge disconnect between the star ratings of hospitals and the experience of patients - my mother was 'treated' in a filthy hospital in a three star trust.
Although Mandelstam blames the target culture and financial performance measures for the problems, criticising PCTs for being focussed on outcomes & throughputs, he concedes that targets were introduced in response to earlier failures. Vast amounts of money have been put into the health service in the last ten years, with good effect in some areas, but Mandelstam doesn't mention this or discuss the allocation of resources and how this affects front-line care - e.g. no examination of the increases in management staff compared to front-line staff over recent years. Nor is there any discussion about the effective use of public money - high rates of sickness absence, use of expensive agency nurses, ineffective purchasing, enormous fees paid to management consultants. This struck me as a serious omission, particularly in the context of care being compromised because of staff and bed shortages.
In summary, the book is excellent at setting out what has happened but is less good in my view at analysing why it has happened and what can be done to improve things going forward. I felt that Mandelstam had his own agenda. He may well be right in his contentions but he didn't always convince me and I think he missed some issues.