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Monday, 27 May 2013

Blowing a gasket

Politicians hijacked the family doctor label and used it to sell the changes in the NHS to an uncomprehending, trusting public. Now secretary of state for health, Jeremy Hunt wants family doctors back in their surgeries doing what they do best as well as running the night shift in order to keep people out of A&E. It’s not going to work.

As a nurse who trained under the old order in what was basically an apprenticeship as well as under the new order in a return to practice course, I felt ‘qualified’ to comment in my last post about nurses. I decried the idea that student nurses should spend a year working as healthcare assistants before being allowed to train as student nurses. 

A month later I find myself writing about GPs – they being the latest professionals under attack from the coalition government. My ‘qualification’ here is more third party. As the daughter of a GP and also the sister of one, I’ve plenty of experience of how the job affects family life and, having worked professionally with GPs, I feel I have an insight into their workload and, to a certain extent, what drives them. And, of course, being a patient gives me the shop window view.

I confess to more than a little hypocrisy, having complained myself about the curmudgeonly, recalcitrant nature that is at the core of many a GP (with no one being more recalcitrant than my late father who took things to another level). However, GPs having long been on a pedestal must now feel they can’t do right for doing wrong. Having been given the keys to the  commissioning purse as part of the Lansley changes to the health service thus distracting them from their day job, they are now being castigated for having given up their night role 10 years ago which apparently has only now started to affect A&E services. Speaking at the King’s Fund recently, Secretary of State Jeremy Hunt, told GPs to take responsibility for the care of their patients out of hours

Hunt complains that we have lost sight of the concept of the family doctor. We? I think he means politicians lost sight of the family doctor when they appointed them as head honchos buying services for their patients instead of referring to them; making GPs responsible for the health of the local population when their skill lay in the clinical needs of the individual patient in front of them.

My local GP surgery, may not implement with gusto all the various public health measures that I think would be a great idea just because they are ‘ideally placed’ in the community but, when push comes to shove, they have always been on the side of the patient. They have provided excellent care to me and my family, expedited appointments and been fantastic support at times of need.

Much has been written about the problems with A&E: the rising numbers of patients being admitted via their doors and the long waits which we thought were a thing of the past. Statistics have been bandied about with a variety of commentators offering their views and reasons.  The pressures on A&E have undoubtedly been caused by a range of factors – a cut in the number of inpatient beds means people back up in A& E waiting for admission. The cuts to social care mean that people may not cope so well at home and seek admission to hospital and, with less support in the community, it is harder to discharge people from hospital.  The whole system is under pressure and the gasket is blowing in A&E.

When it comes to the arguments over A&E numbers, I found the King’s Fund’s John Appleby’s blog the most compelling argument for why numbers were increasing and why there’s no need to panic:

His logic has to make you wonder; is the media storm over A&E nothing but a stirring of the hornet’s nest creating an impression of a ‘failing’ NHS that needs saving by the private sector? Hmmm, can’t see that working either. If there’s one thing that presents at the door of A&E it is ‘difficult’ patients and that’s one thing the private sector doesn’t want. ‘Difficult’ patients with complex social circumstances, co-morbidities and distressed relatives are time consuming and expensive. Paying for care at the entrance of A&E would truly be the end of 60 years of care free at the point of delivery. I wonder when that idea will be voiced?

Monday, 22 April 2013

Cheap labour

Potential nursing students should spend a year working as health care assistants before they start training, says the government. A move described by the RCN as ‘stupid’

I couldn’t put it better myself. The story first broke at the end of March but I hoped it had merely been suggested to test reaction and would not rear its head again. But no, here we are at the RCN congress and the government, dogged as ever, especially when it’s wrong, is going full tilt.

It’s an idea that completely misses the point of the recommendations of the Francis report and tries to lay the blame for the travesty of Mid Staffs on nurses, whilst Francis laid it on the NHS Trust Board and the strategic health authority. 

How anyone thinks that unleashing untrained people, often teenagers straight out of school, on patients with multiple care needs, will improve the care of those patients is bewildering. It demonstrates a complete lack of understanding of nursing and, I would suggest, of education.  If you don’t believe me then read  for a nurse who really knows her stuff.

Nursing is and should be a career, where educated people can be both caring and ambitious. The two are not mutually exclusive. Nurses can specialise and become expert in their field – increasingly a necessity in an advanced health service. There will always be room for generalist nurses but the days of a nurse being able to ‘work anywhere’ are about as realistic as expecting an athlete to be able to compete in any event just because they can run fast. Yes, nurses need to be caring and compassionate but they also need to be intelligent, educated and forward thinking.

How will a year spent as a wage slave facing the more grim aspects of life make someone compassionate and enthusiastic for more? Many young people will be more than up to the job and still want to go on to do their nurse training. But many, who would have made excellent nurses, will not. The ability to deal with the smell and misery and sheer grossness that comes with caring for the very sick, the very old and the dying takes maturity, understanding and compassion. The latter is not produced automatically like an inborn kindness duct present only in those who can be nurses. However, it will almost certainly develop as someone matures and is certainly something that can be learnt with the support of good tutors and good role models. 

The age old dichotomy between ‘educated’ nurses and ‘trained’ nurses is tedious and usually put forward by those who are not nurses or have been out of the profession so long that they can’t remember the bad old days.  Why would you not want your nursing workforce educated? At present student nurses spend more than 50% of their training in practical learning – on the wards, in the community and in skills labs. What will another year of hard graft at the minimum wage – making their training an unrealistic four years – add to the mix? 

Put young people fresh onto wards and into care homes and there is no knowing who their role models will be. Much of nurse training may be spent unpicking some bad habits and corner cutting learnt while on a year’s ‘compassion training’.  And anyone forced to do a year of apprenticeship might well see themselves above having to do any of the dirty work once they are trained – there is an army of untrained youngsters for that – thus having the opposite effect the government intended.

But of course this is not about nurses, nursing or patients. It’s about filling jobs cheaply with young people thus solving the care of older people and the young unemployed in one hit.

Learning unsupported and unsupervised will be bad for nurses, bad for nursing and bad for patients.

For more on the good old, bad old days: Remember when?

Wednesday, 20 March 2013

Positive about health

Recently, I attended the Public Health 2013 Achieving Positive Health Outcomes conference. Aside from the fact that the word positive in a health context is not always, well, positive, (think HIV positive) it was interesting and stimulating to be amongst public health colleagues. In particular, it was good to hear from the determinedly non-pompous head of PHE, Duncan Selbie who talked about ways of working and yes, positive attitudes to colleagues and others.

The purpose of the conference was to introduce local authorities to issues in public health now that, as Roy Lilley so eloquently put it in his blog, it is ‘stuffed up the back passage of the town hall’. So, there was a lot of hard sell from private companies hoping that local authorities would commission them to provide weight management services or active lifestyles at a price. Don’t know why; local authorities are strapped for cash and that lovely ring fenced public health money is not going to stretch to anything other than the most basic, but hopefully effective, public health interventions.

It was not all commercial sell and there was a presentation from the public health team in NHS Wiltshire and NHS South of England on the excellent work they have done on tackling unintended pregnancy in the region. This was through incentivising GPs to train to provide long acting reversible contraception (LARC) thus increasing access to contraception across the region. GPs had their training paid for and additionally, for each implant they are paid £61 (and the same for removal).  All funded by Improving access to contraception monies. Whether that programme will be sustained now that funding is coming to an end remains to be seen. Will GPs continue to provide the service if they are not receiving payment for it?

Ironically, the conference was held at The Brewery Conference Centre, which, when I was training as a nurse a million years ago at nearby Bart’s Hospital, was still a working brewery - dray horses and all - but is now a beautiful conference centre. However, its association with alcohol seemed slightly at odds with the promotion of public health or, as we were regularly reminded, the public’s health – as if we hadn’t thought about that before.

The alcohol link was not direct sponsorship more just an association so I got over it. But coming in the week that it did with minimum pricing for alcohol looking like it was taking a dive, it did make me think. Is alcohol advertising, promotion, branding, its very presence all around us as pernicious as we now consider that associated with smoking?

There was a time, not so very long ago, that tobacco companies sponsored a vast array of sporting events and no one thought anything of it but as smoking has slowly become almost as antisocial as, say, drink driving, is alcohol becoming the same? I don’t think there’s a lobby to ban alcohol completely - it is not quite the killer that smoking is and, let's face it, prohibition was a disaster.

However, there is no doubt that ‘something has to be done’, if only to rein in our enthusiasm for alcohol. Drinking is so easy. It’s easier, in fact, then smoking. It’s always been frowned on at work unlike smoking which was once a part of office life, and those employees who drink at lunchtime are a rarity these days, but buying alcohol and consuming at home is so easy and so cheap, compared to a generation ago.  And culturally, it’s acceptable. Smoking is no longer culturally acceptable. People might at best feel sorry for you if you smoke but they won’t joke and laugh about it and share their smoking stories like they do about drinking.

Studies show that minimum pricing does have an effect on drinking levels in the population with one Canadian study showing that a 10% increase in average minimum price for all alcoholic beverages was associated with an almost 32% reduction in deaths wholly attributable to alcohol. The study by Tim Stockwell, Jinhui Zhao and colleagues showed that there was also a time lag in the impact with fewer deaths from alcohol two or three years after minimum prices were established.

Certainly minimum pricing will not solve all alcohol woes but it might be a positive step towards acknowledging that we may have a problem. And that first step is important in any addiction, whilst a positive attitude is essential in public health.

Tuesday, 29 January 2013

Going up in smoke

At last! Smoking -or rather not smoking - is beginning to show health benefits in the here and now that are more tangible to your average smoker than scary warnings about cancer and heart disease in the distant future.

Two recent studies have reported on the benefits that not smoking is having on young people. One in Pediatrics reported a sharp fall in the number of children admitted to hospital with severe asthma, linking it to the smoke free legislation introduced in England. Whilst another study in the US published in the American Journal of Public Health reported on the effectiveness of smoke free air laws and state tobacco control programmes on preventing youth smoking in the US. 

Earlier studies reported on the benefits to bar staff that the smoking ban has brought - for example, reductions in respiratory illnesses whilst other studies have reported on the reduction of admission to hospital for acute coronary syndrome.

The asthma study found that in the first three years after the ban on smoking in public places, introduced in England 2007, the number of admissions to hospital for childhood asthma was down by 6,802. Before the implementation of the legislation, the admission rates for childhood asthma were going up by 2.2%. The results were the same for boys and girls regardless of whether they lived in towns or rural areas, whether they were poor or wealthy. A similar fall in Scotland, where the public ban was enforced a year earlier was reported in a previous study.

The study allays early fears that there would be an increase in smoking at home if people were not allowed to smoke in public places. In fact, the researchers from Imperial College in London said that it appeared  that more people are moving towards having smoke free homes instead.

Capitalising on these benefits is key if public health is to maintain some sort of momentum to reduce smoking and ideally prevent children taking up smoking in the first place.  In recent years it seems the twin challenges of obesity and alcohol have come to the front whilst anti –smoking has been pedalling furiously behind. 

But the recent scary TV advertising showing a tumour growing out of a cigarette and the launch of the Department of Health’s recent Quick Kit Campaign should see the stop smoking agenda back on track. And not before time, as another study published in the New England Journal of Medicine into women and smoking reported a steep increase in the risk of women smokers dying from lung cancer – attributable to more women smoking and also a decrease in mortality amongst women who were non-smokers. 

As my grandfather (the first in four generations of doctors/nurses/midwives) might have said: the three greatest causes of death are: smoking, smoking and smoking.

Millet C, Tayu Lee J, Laverty A, Glantz S, Majeed A ; Hospital Admissions for Childhood Asthma After Smoke-Free Legislation in England Published online January 15 2013

Farrelly MC, Loomis BR, Han B et al; A Comprehensive Examination of the Influence of State Tobacco Control Programs and Policies on Youth Smoking. Published online January 17 2013 Am J Public Health.

Thun MJ, Carter BD, Feskanich D, et al. 50-Year Trends in Smoking-Related Mortality in the United States. New England Journal of Medicine. Published online January 24 2013