The Health Care Challenge - Serial & parallel Endemic Crises.General Introduction:Look! I am not a Nurse. I feint at the sight of blood and needles. I was carried into hospital by my mates, the last time I desperately needed a tetanus jab. I have 'perceptual' dyslexia and some poor sod is likely to get the wrong meds; is it "Citilapram instead of Citrazine", maybe. I once feinted in a hospital waiting room, waiting for a lady (with the effects of polio) to have orthopaedic shoes fitted. I know my limitations. I get palpitations just listening to a heartbeat. A stethoscope is out of the question. I even have to avoid techno music and heavy Tamla Mowtown (which I love) because of the beats close resemblance to heartbeat, which may bring on an attack of anxiety. I am an unashamed anxiety neurotic, near psychotic, hypochondriac, who has, in the past, been so concerned about what physical illness I may get, that I frequently miss the early stages of 'real' health crises. Don't get me wrong, I know what I am good at and I am aware of my areas of limitation. Dealing will physical illness just makes me sick. Dealing with mental illness just happens to make me feel reasonably normal. Medicine is just such an area of personal limitation, with the exception of Mental Health and Dementia, but then again, these are as much social problems as they are clinical ones and it is in this area that I perhaps excel. In these areas I feel that I have close affinities (a little hypochondria and a little for real, but apparently not dangerous, or high risk). This said, I am close enough to the Health Service. I currently work within the service - having overcome my phobia of hospitals and cheap disinfectant; to recognise that serious problems exist for practitioners, manager and executive, struggling to do a mature, good quality, progressive, professional job. I have also worked along side, in tandem and sometimes in competition with, Health Professionals for some 35 years in all. I am also, slightly detached from the 'medical', or 'clinical' side of things to have a fresher, less institutionalised perspective upon the Health Service organisations. In the fields of Learning Difficulties, Physical Disability, Mental Health and Drugs and Alcohol (all f which I have specialised in) I also come from a severely critical perspective on the clinical practices of 30 years ago, to one of mostly significant respect, even by comparison with my own, largely ailing professions within Social Care field. I am positively surprised by the degree that clinical practitioner's have taken the 'social care' perspectives on board and incorporated these into their more clinical perspectives, presenting, once more, a human face to the patients. The situation is not perfect of course and there are some die-hards, mostly (sadly) promoted to positions of power, or assigning themselves such powers. By working together, the health and social care components of the comprehensive provision, increasingly understand each other better and can share the middle ground and appreciate the competent and incompetent aspects of each imperfect profession. It is good to see the return of the old principles of the General Practitioner, as being the prime focus for all the physical, psychological, emotional and social ills in the local community. This expertise is now rightly being transferred to other, empowered, modern Community Practitioners. It is good to have a primary focus, hence the term 'Primary Care'. It is just as important that this holistic focus is maintained up through secondary, specialist levels of care. Health is a social issue also, as much as social issues have historically been of concern to general health. The issues that we need to deal with are complex and we cannot hope to deal with all aspects in the first hit. There is significant defensiveness in the health services, as there is in social care fields. We are scrutinised incessantly and the unrealistic attitude is that we must always get it right, take responsibility for all aspects of a person's health & social care and accept culpability for all failings, including those beyond our control and those that reside with the Patient / Clients current, or previous conduct, however much this impacts their current condition, or situation. I was taught a very simple but lesson, by a very insightful Tutor, at a vocational College, which gave me insight on human rights that I had previously neglected to appreciate. He had heard me pontificating about Human Rights, as these applied to disadvantaged people. At the time, substantial numbers of people were socially isolated in large institutions, away from public concern, on the basis that they learned slowly, were at risk of corruption, failed to maintain moral standards and all manor of other 'Victorian' justifications. He acknowledged the injustices that I and others had observed, he sanctioned the continued campaign to ensure that public awareness was raised, that the Legal entitlements were respected, as with any other citizens, and that the ratification of the United Nations Conventions on Human Rights was fully respected in ensuring disadvantaged people obtained liberty, respect and equitability within the law. The one simple addition he made was that these rights carry commensurate responsibilities. Both general principle have been applied equally since. On this basis, it is easier to understand that responsibilities and obligations are shared, between ourselves as representative professionals and the person who legally requires, or rightfully expects our support and expertise. These obligations and responsibilities are applicable, in as much as the person has the capacity to understand their entitlements and the associated responsibilities, both to self and any legally defined impact on others. Put succinctly, a legally defined impact is where it is evident that a behaviour (or absence of a behaviour), is a contravention of the Law in some way that any citizen may be brought to book. Our patients and clients, whatever their condition, have that same entitlement to consideration and sanction within the Law, although their recognised vulnerability may protect them from the full force of any normal processes, or sanctions, commensurate with their capacity to appreciate these errors, their consequences, the legal processes followed and the sanctions chosen. By these basic criteria, what can not be automatically and legally included, as evidence of lack of capacity (or of a MHA mental incapacity), are rightfully and legally angry, or indignant resistive reactions, in response to any intrusion, including attempted legal interventions, that result form a concern that the person did not have capacity in some other important respect. The person's lack of capacity, in respect of legal interventions, should protect them from normal processes and sanctions imposed and should not be used as 'evidence' of the person's mental ill health, or Mental Incapacity, within the formal processes of the Mental Health Act. If they do not fully understand the reason for 'intrusion' they can not be held responsible for their reaction to inappropriate, insensitive approaches, normally tolerable, if not generally acceptable as good practice. Kicking in the door to someone who refuses to open it (out of fear) and the person being told 'OK mate, you are knicked', as two or three coppers pounce on them, does not indicate any professional insight into the potential problems the person behind the door may have. Similarly, walking into a persons home (as a small group of relative strangers), presenting ourselves as a friendly support and then informing them (even in the most sensitive, self reflective way) that their freedom is going to be taken away from them, can be expected to generate anger and potential violence as a natural reaction. When, in addition, the person does not adequately understand (by virtue of a separate lack of capacity) why this should be the case (because they do not appreciate, or accept the 'grounds' for the intervention), it makes these reactions even more 'understandable and natural' in all other legal and Human Rights respects. If the behaviour is in the 'normal range' that we may expect from people, given their varying 'normal' personalities, knowledge and insights, then the reaction for any 'intrusion', of any 'style, can be expected to be met with 'natural' resistance, in keeping with that persons general character. It may be evidence of a misdemeanour, by virtue of an 'overreaction', which will have to be dealt with as a separate matter in law, but it is not evidence (of itself) of a / the Mental Impairment, or more general lack of capacity. This above policing approace makes good TV and may feel appropriate action towards hardened villains and belligerently antisocial, or even sociopathic individuals, but is very bad policing if applied, as a frustrated response, to any irritating, unresponsive 'alleged' criminal (with a record or not). Action in response to fears (real or in some way exaggerated) are psychologically and legally different to those aggressive actions that are out of belligerence and resentment. These, in turn, are quite different to those behaviour that are calculated and abusive. The Law is and inaccurate instrument. It is a system of best gueses, hunches, interpretations, logical arguements does not apply as reasonable criteria for judging the lack of capacity in respect of the reason for the legal intervention of any kind. or a public nuisance because of irritating characteristics, an embarrassment, irritation, being identified as a personal, or public health hazard because personal standards are lower than the average. does not apply unless these transgress the Law. Civil law will deal with these aspects, if the actions meet the criteria. (and risks of neglecting them) and the inherent responsibilities, to self and others, in any particular area of these rights and responsibilities. Where intervention will contravend Included in our general responsibility to that person are the Family Carers, in that they may ontribute to the legitimate, tolerated, requested or demanded support of that person and members of the community, who again make a legitimate contribution, or who are legally affected by My allegiance is to the client / patient, their family carers and the Community, in that order. It is not an alliance to particular professional instrument, who's duty is to provide the resources to meet Legal and Professional obligations. My allegiance is to the higher order of ethics and principles in general, incorporating the Conventions on Human Rights, it is not simply dependent upon the more limited requirements in law and the interpreted rules and policies of institutions, except where these fully meet the requirements of Human Right, Ethics and Principles. Laws, in general, prescribe the minimum conduct required of us as citizens and intuitions are inclined to meet the Laws requirements to the letter rather than the spirit. Law relating to all aspects of Human Rights are underscored by all the Convention of Human Rights. Assigning these rights when interpreting these Laws will more likely ensure they are interpreted in the spirit in which they were intended. Viewing Laws, Policies and the Conventions on Human Rights through the lens of Ethics ensures justice and equity. The Communication Problem: I have asked a few Nursing colleagues to write a critique of the situation for modern nursed but have not got any volunteers so far. This is mainly (they say) because they are to busy. I can understand that argument, but I think the main reason is that they often feel unable to publically criticise the services they work in. It may also be possible for them to be identified by what they have written, even if they chose to be anonymous. There is some real fear, based upon the evidence of those that have done it, about engaging in public criticism, within the media, without 'appropriate' permission. It has been suggested, by service managers (and I am sure that it is quite possible), that anyone making identifiable statements to the press, or on radio, will be threatened with disciplinary action. It is contained in one of those famous Policy Directives and has been given as warning to some braver individuals, making very reasonable, essentially 'constructive' statements about providing the service. My own perspective is quite simple. Such public criticisms are quite reasonable, especially where one has made reasonable representation to service managers, concerning challenging and of often unrealistic expectations and demands being made on personnel, or unreasonable & avoidable shortfalls in services. This is especially where it is felt to be in the public interest (and in the interests of protecting staff health, patient safety and the quality of service), especially where the criticisms are adequately evidenced. Everyone's entitlement to express their reasonable opinions, publically and lawfully, are protected by common rights, the conventions on human rights and British Law. The exceptions are; statements that may be deemed to be libellous or slanderous; those which affect the security of the state; behaviour which is in any way provocative towards race, colour, culture, personal religious beliefs, etc.; or that which may incite others to violence. In all cases this has to be proved. The special case that affects us are statements that contravene the professional and agency agreements on confidentially and privacy laws, which require us to keep identifiable details of innocent parties and especially vulnerable people, anonymous, even where there is a public interest in making general, and non-identifying specific information available for public scrutiny, etc.. The national law is not as 'tight' in these various respects as people tend to expect. Legal advisors may be more, or less, cautious in their advice, protecting their own position. How much funds we have for paying them is also a significant inhibitor of fairness and justice stakes. In the end it is our decision to judge what is reasonable and what statements we can support in rational argument and with evidence appropriate and mitigation. Human Rights are our ultimate security, and although the process to this level is slow (in the appeal process) it is the final arbiter of what is our entitlement in law. If we can demonstrate, at the earlier stages, that out freedom of expression is being sough and used, to protect our own and others freedom of expression and to ensure our own and others dignity, safety, security and other entitlements, we are well provided and protected by the Conventions on Human Rights. Go for it. The only other, reasonably secure method of curtailing free speech, in respect of organisations we work for, is when there is an explicit, signed contract to that effect, waving our usual rights in this respect. Referring to existing policy has only limited curtailment of public expressions, where there is no 'culpability, due to serious errors'. Even such a contract is null and void, where conduct of the employing agency and/or its agents, are so unreasonable, or detrimental to an individual's, or a groups well being and therefore in the public interests. Of course, an abusive and controlling organisation, or the individuals within an organisation, will 'punish' anyone who speaks out against unreasonable, abusive and neglectful behaviour they suspect , or detect. That is a price we sometimes have to pay, for sticking to ethics & principles. If we have been honest, have made best efforts (under the circumstances of disclosures) to make the issues known to those with the power to intervene and then taken what opportunity there is to get the problem adequately resolved, we have little ethical choice than to 'go public'. In doing so we will still have some protection in law, regaining our rightful opportunity to express the facts (and allied opinions), on public interest matters, 'in public' media, if necessary. The very attempt to 'stifle' such disclosures and to seek to avoid culpability for failures, neglect and abuses, is criminal. Good recording should be made, of the detail of the events and other evidence, with considered summaries whenever this is possible. Any attempt to dismiss, displace and undermine evidence and individuals should also be recorded. Public statements, based upon evidence and reason, are appropriate and do not constitute a misdemeanour. The fear that 'a person's card is marked' is very real and understood though, and is a further serious inhibition for many people. On the other hand , I don't believe the challenge to such disclosures is as severe as managers suggest, if done constructively, especially if the issues have been discussed within teams and more widely in an organisation. Managers at lease have to give the impression of being in control of their services, this includes awareness of the 'mistakes made' and the process of investigation and correcting errors. We need to simply satisfy ourselves that that take this employer responsibility seriously. It is primarily their job to sort these problems. It is only when they fail to do this to your own and others satisfaction that more public, directed action should be taken. More general reflections are always allowable bu have to be 'interesting' to get aired in the media. To be continued .... It is also early days for this web site and it has not proven itself as a vehicle for expressing the frustrations of working within a rather defensive, relatively under resourced and rather institutionalised service. There are no secrets here, really. Patient and Carer criticisms are tolerant and understanding in the main but the criticisms are there and fully understood by staff and patients alike, as representing serious shortfalls. Many of these shortfalls are not directly attributable to the independent incompetence of service managers and staff. Many are the consequence of paperwork exercises, implemented, rather naively, to protect and develop the services. These Policies and Laws often clash with the professional ethic, which has a higher order of status, considering quality as well as quantity. That said, there are, of course, incompetent managers and practitioners, many of whom started out that way and did not require inducing into that state. You must be the judge of this, it is your responsibility and a difficult task. It is no longer possible to ignore the problems. As pretenders to being 'independent practitioners' you have the obligations that go with the professional and ethical mantles. The very basis upon which the health service is provided remains as tentative and unreal as the earliest days of its existence, no amount of massaging has made any real difference. It is a good 'ideal' made to work, by ignoring the impossibility of it all. Make it more commercial and we all know it will dissolve in a puff of smoke. The Health Service, along with Community Care, are the Bumble Bees of statutory services. They should not fly, but they do none-the-less, because of the exceptional efforts that have been put in to ensure this is the case. This is mostly by dedicated people, who do the job without, and in spite of, the managers, if they need to. They are capable of working from fundamental principles and professional ethics, in advance of common place prejudice and stereotypes. Although not totally devoid of prejudices and judgements, they are preferable to the ignorance and interference of the more institutional and commercial forms of organisation and practice. Much of what has been written here can also be said of Community Care initiatives, which have their impact upon the modern Health Service also. This initiative is also idealistic principles, made to work against the odds and involving recriminations up and down the management line. The job still gets done, by those that care enough. This said, the buck dose have to stop somewhere. In employment and institutional terms, it is with executive managers, who, with the best will in the world and the very best of intentions, have taken of the mantel of power, taken the kings very inflated shilling, promising to stay faithful to the cause and to meet the obligations promised in the contract they proposed (and got accepted), when they enlisted. And so, on with my accounts: A Temporary 'Outsider' Critical Perspective: Well, in the absence of 'in house' perspective I will do my best to express some of the difficulties, criticisms and frustrations expressed to myself. To put this in context; I have been an 'involved' observer of health services many years and have worked very closely with health service colleagues. In the past I have made severe criticisms (pre Community Care) of the service provided to those with learning difficulties, mental health problems, disabilities and older age services. These where mostly because of the endemic, institutional, detached, disempowering, 'expert', attitudes and treatments. The attitudes of most professionals have improved immensely and mature, none-condescending, respect for the individual (especially in these critical areas), has improved substantially over the last 20 years or so. Most staff do the best they can in the circumstances under which they are expected to operate. The Health Service has moved on and the institutions have changed their attitudes at a professional level, at least. The move towards 'patient involvement', although limited, is a positive move. Unfortunately, the institutions have also 're-institutionalised' these new perspectives and the essential quality of the new philosophies, concerning this specialist patient care, has been distorted. They have been made 'paperwork' requirement rather than real efforts to support the changing attitudes of professionals. There is a real misunderstanding at the more executive levels, of the nature of the necessary 'empowerment' of service users. Staff do their best but the institutionalised policy is a big inhibition (Health Care is not alone in this). 'Commercialised' processes have not improved the situation. We talk about 'informed choice' and 'patient participation' in developing services, but these principles are often just nominally adhered to. Providing a 'paperwork' channel for suggestions and complaint and offering 'advertised' service / manager lead 'forums' for users to express their opinions, on already proposed local services and changes, is actually divisive. Getting real, empowered, patient participation is hard work and is a strategic issue. This has not been properly engaged in, mainly because of ignorance. We found this with 'learning difficulties' services 30 years ago, at the outset of the initiative for 'Community Care' services and principles. It is hard work, getting real, empowered, constructive and inclusive participation. It is hard work getting your head around the 'mind set' that is required. Professional managers I have met simply adapt the process that they are used to, rather than stepping outside the box, as is required for such required significant changes. Institutionalised thinking makes us blind to new opportunities and the benefits these offer to our patients / clients, and ourselves as professionals. The Problem with Health Care Services (a Community Care perspective):I can see lots of things wrong with the Modern Health Service and have been around long enough, and worked in cooperation with Health Care Professionals often enough, to know that good practitioners, in all specialist professional fields, are very self critical (and often defensive). I know they are frustrated by the resource and the philosophical restrictions that hamper their attempts to adhere to their established Ethical commitments and obligations, against the institutions contradictory and 'paranoid' fear of litigation. Advancing the more 'radical', government proposed, service and professional initiatives, is even more challenging under there existing, restrictive resource and intellectual conditions. Even Government agencies often inadequately understand these new proposals, which were originally developed by enlightened professionals, trying to solve existing problems and advance the quality of the services provided. This new 'attention' to professional services includes radically adjusting how services are applied in the patients best individual and collective interests, and with the patients greatest inclusion at all stages, with informed (educated and experienced) choice. This is not simply a modification of what previously existed. It requires a new way of seeing and understanding. It is an easy mistake to make in simple adjusting the paperwork systems. These proposals can be read simplistically as 'doing hat we do already'. I have been particularly aware of the frustrations and challenges that my Nursing Colleagues have to face in recent years. Demands and expectations are high and resources relatively low. Much of the remaining, available resources (after paying for the Executive, Consultant and GP and Staff level pay, benefits and resources) are displaced towards the administration and monitoring processes, which are detailed and comprehensive, but increasingly so unrepresentative of the realities, to to be really useful, precise, or accurate. These increased monitoring and administrative obligations are geared towards achieving nominal targets, reducing waiting lists, reducing bed places, defending potential areas of litigation, multiple form filling for different interests, complex and ambiguous PCT funding requests (CHC in particular) and service level recording, to justify spending. Valid activity, if done by administrators, producing accurate information, to support Executive Levels of Management in identifying service demands and costs. In terms of practical realities, it is often more work for less effect. Its the Garbage in Garbage out principle. Sadly Managers are often playing the Alan Sugar, pseudo-entrepreneur, 'Bully Boy', 'Your Fired', Commercial Game. The 'efficiency' quotient of most professionals has been exceeded and we all know it. Many of those who choose to do 'enough to get by' are often justified in doing so because of their frustrations, disillusionment and personal and social health effects. Pushing 'efficiency' further has put us into 'negative' efficiency. Stress and despondency, along with these ineffective administrative processes, have reduced effective practice and we should not surprised. This has meant that there has been some limited improvement in quality at the top, more charismatic end of the service, with a disproportionate reduction of 'actual' services at the bottom end. It is becoming a crisis service with little attention to working at avoiding these expensive crises. GP level services are now expected to provide these early stage, specialist services but they are ill equipped and relatively ill informed to do so. This will improve as GP's and their ancillary staff, become trained and experienced but there is always likely to be inadequate specialists, because of the costs involved. Cost have gone up significantly and unnecessarily so. The actual pressure on hospital bed demands are increasing, as Community Services fail to meet its objectives fully. This is because of the distractions and distortions created by the inefficient and inappropriate implementation of these 'new' initiatives in their own case. On the other hand, contracted Community Care service costs are relatively too low for the level of service that is required of them. They are suffering the same 'efficiency fatigue' as other sectors. The consequence is a constant juggling between statutory, commercial and charitable services to achieve short term cost benefits, which have impact upon reduced quality of service. Similarly, there is a constant battle between Health Care and Social Care responsibilities and funding, and then between General and Specialist professional services and funding. The 'Mind the Gap' principle is practically ignored, as one professional group blames the other professional groups for the 'gap'. Those with the greatest professional commitment attend to the gap and for their efforts, are often penalised for their ethical efforts in ensuring patient / client safety and quality of service. In filling the gap they have actually saved costs, but no one is keeping the accounts in this respect. It is not their business. The gap is part of the boundary of their domain of influence and power. Just like a feuding family, without enough to go round, each blames the other for the disproportionate share they have. Some may even be gorging, in order to ensure they don't loose out tomorrow. This fundamental principle of appreciating the 'cost benefit', and 'efficiency' limits has been know for many years, the concepts of 'built in redundancy and resilience' has been understood in engineering for thousands of years. It has been understood by some practitioners and managers in the Health and Social Care since the 1970's. Re-building a bridge, each time it fails, is not cost effective. Rebuilding services when it has been screwed up is no more cost effective. Get an intelligent perspective on things, people. There is a limits to cost saving, beyond which there is incompetence, neglect, risk and culpability. It just needs pointing out in Law. Hi there :-). I am pointing. How can I feel so confident. I have actually 'consistently' improve local services, client / patient participation and staff morale, with actual, accounted reduction of costs. It can be done, once the concepts are fully understood. I have done this in the statutory sector and the voluntary sector, involving 'service users' and service user volunteers and support groups. If we are not to precious about our skills and not to possessive of our power, service users (with encouragement, informed choice, professional supervision and a few resources) can help themselves, individually and collectively. Those few 'spanners in the works' (who never wanted Community Care in the first place - it takes away power and control) point a finger and say: 'Look, I told you, we will always require larger institutions and lock people away for the sake of the community and themselves'. Such attitudes cost our services in terms of quality of service, human rights and actual, longer term, 'relative' cost savings. They are blatantly wrong and, are actually part of the problem, particularly if they get to senior positions in services and especially if they become 'part converts' to the 'idea', rather than disciples of the fundamental principles and the spirit of advancement of professional services. The Inefficient Service Administration:There is a felt requirement for recording detailed accounts of none-risk (as well as high risk) events, just in case they are identified as precursory to a crisis, where they may be held culpable. This 'fear' is incorporated in the content and volume of Policy Directive that institutions produce. Intelligent professional autonomy is required here. Professionals need to discriminate what is priority, given the presenting problems and resources available. To do this they need to declare the general shortfall as a singular statement, saving having to record general and well as specific shortfalls, in individual cases. Accounts of important, or possibly salient events, are necessary but need to be discriminating. In practice, responsibility and accountability has been passed down to Health Care, without providing adequate status, authority, or explicit permissions to challenge, or rectify the anomalies and shortfalls. All this is often done with totally inadequate administrative support. The arrangement is punitive, inefficient and distracting for the primary purpose. In fact (to use an analogy) if you take the eye off the ball, in order to attend to what the referee may do, or what the linesman may be thinking, then it is going to be a very boring and ineffective game of football. The chances are, in fact, that the consequences of such distracted and defensive attention, is that you miss the real chances to intervene where there are risks, or where there are opportunities to progress the game. You, your team and your fans are going to loose, not just the game, but the credibility. I have watched Community Mental Health Teams (which are central to the Government's and all party commitment to Community Care), diminished to less than 50% staffing levels with Referral Rate, Policy and Ethical demands remaining unchanged or increasing. This has been done on an unplanned basis, usually for the purpose to reduce costs, by maintaining vacancies as long as possible, and indefinitely in many instances. The argument is that it is the managers job to control finances and overspend. I am aware of the increasing Health and Safety impact of high levels of unreasonable work stress, affecting practitioners work, environmental risks (driving while under pressure and while stressed), personal health and normal family commitments. I am aware of employee's caution in expressing these frustrations and the increased Health & Safety and patient risks, for fear that this will be identified as a 'professional competence' issue. I am aware of managers who have made warnings on this bases and who have even acted upon those warnings. I am aware of the disproportionate improvement in Employment Benefits to GP's and Consultants, with an associated reduction in the time commitment to coalface, of out of hours work and home visits. The contracted PCT / GP commitment to providing the Primary Care level, Specialist service are practically non-existent, or 'under skilled' in critical specialist areas. The neighbourhood teams are late being introduced, the service is not transparent, it is administratively difficult to engage and is another postcode lottery. This slack is expected to be taken up by specialist, second tier, Community Nursing and other Specialist Health Care professionals, often manipulated to take on Primary Care (PCT) responsibilities, by inappropriate referrals and emotional pressure to attend to evolving crises, because of the lack of specialist resources at Primary Care level. GP clinics and the Specialist second tier professionals are in another double bind. They either stick to the brief of 'neighbourhood teams' and insist on the referral to them, although resources are known to be inadequate or absent; or, they take responsibility for meeting the burden of the referral, without the appropriate authority, or paid for resource allocation; or they refer on to the Local Authority services (who are partially paying for the Neighbourhood Teams resources already); or leave the gap there, hopefully declaring the fact that there is a service shortfall (as they have the responsibility to do). To be continued. . . I have provided the following accounts of crises in specialist Ward and Community Teams as a modern example of the kinds of challenges and stresses that Health Services meet all the time. The accounts given here are not particularly untypical of the situations that arise in many Health Trusts, operating under quasi-commercial conditions. There is no particular blame associated with particular individual, mainly because everyone is culpable in some way, all the way to the top and beyond. Government want he glory for the effort of others, without the responsibility of the consequences if implementation. People want the services without paying for them trough their pay packet. The 'well off' individuals want piece of mind by cheaply locking up the problems and pretending they are not an important part of the problem. Most of us would like to bury our errors and embarrassments. Most people have become skilful at projecting problems onto those least able to defend themselves. Community Beds in Community Hospitals:In the age of Community Care, the earlier product of a Community operation, Community Hospital, are being closed by PCTs and their 'local' services purchased and provided by larger, more distant, district hospitals. Local services will eventually transfer to GP run services and the fanfared (but under staffed) Neighbourhood Teams. Unfortunately the GP services and Neighbourhood Teams are not ready for this transfer and there will be a 'gap' for some time yet (remember 'Mind the Gap?). This retrogressive change is all the more ironic, as many of these Community Hospitals were the radical initiatives of forward thinking GPs. They had the foresight to realise that those most in need of hospital services were the least able to travel great distances. The elderly infirm, those with dementia, physical disability and acute injury follow up treatment, low key emergencies, not requiring emergency calls but requiring immediate treatment; all benefit, with reduced overall cost to the Health Service and supposedly precious GP time. Of course, in the tradition of commercial short term thinking; the land which Community Hospitals occupy is a natural resource for bailing out the armature entrepreneurs from the financial mess they have got themselves into. Originally promising 'something for nothing and the best for free', in order to win the bid to be able to provide services. They fully appreciated initial price to be paid with reductions in local patient service and excessive work stresses for other staff teams. That illicit resource has now depleted, the Emperor is recognised as being naked, and shamelessly selling of the family silver is all that is left. Ward & Bed Closures and Transfers:I recently experience the closure of a specialist ward, within a Community Hospital, which had a cohesive staff team providing an expert, responsive and quality service to local patients with dementia, and their carers. I am a severe critic of all services, my own included, so this is praise indeed. The service offered respite for those who had significantly challenging problems, and was effective in promptly assessment & assisting resolution of acute crises for people who had long term, progressive conditions. The team was cohesive, highly professional, effective and about as efficient as a public service can get. It was well managed in its original old building and also its newly appointed one. I know of no patient, family Carer, member of the community, member of staff, Consultant, or of any significant numbers of GP (who's PCT had a vested interest) who did not challenge, or express their dismay at the closure and pretended transfer of this services. It was such an irrational move that no one, even now, believes it was rational and considered. The evidence indicates likewise. It may improve but that is a separate consideration and will require effective, higher level, management input. The argument that the same quality service could be provided in other ways, at reduced cost, at other locations, is complete poppycock and frankly delusional, or dishonest (take your pick). I have never experienced a more collusive and dishonest set of arguments for a ward closure, or service changes. The same agency manages the alternative site, which it is still in the same dilapidated condition, a physically and psychologically depressing environment for patients and staff alike. Transferred staff have the most miserable task of trying to help transform that environment, but those that remained will try. The existing, well established, Auxiliary Nursing & Care Team (at the alternative site), effectively run the operation in their embittered self-interests. There is no other way to put it. Professional staff mostly do what they can to provide an adequate service in spite of them. The situation is so well manipulated that you only get the full impression if you visit on a low key basis, out of normal hours. When necessary, the whole team can pull together to meet obligations but the quality of service, as described (and feared) by patients, ex-patients and family Carers is unmistakable. Few want to go back. Professional staff have been very competent (for reasons I will explain) at 'compensating for' the destructive element, who they are often powerless to challenge, because of the largely subversive activity. It is not unusual for members to 'set up' professional and and more senior staff to appear to fail in their duties. Reports go missing and entries get lost. There is enough 'fear' in these Health Trust institutions in general. Any additional stressors and uncertainties generated within the institution, can be highly destructive. It is, without a doubt, a time warp situation. There can be no excuses, check it out for yourself. How does such incompetence go missed?: While overstretched professionals risk disciplinary challenges, because of their stressed failures to follow paperwork procedure; while stressed managers are challenged for bullying approaches towards administrating unsavoury staff reductions and changes (inadequately supervised); while staff fail to meet requirements to utilise ineffective & inefficient information systems (demanding most of their now increasingly, very precious patient time); while ground floor windows in office quarters (along with all other buildings) are made safe against suicide attempts by disillusioned staff; these 'bandit operators' continue to reduce a service to the bare essentials at times and towards significant, largely hidden risk at other times. How CSCI miss such incompetence astounds me but sadly, does not surprise me. This small band of dissonant and destructive workers continue to practice, in spite of their known existence by Managers. This core group have reduced patients & staff to a state nursing purgatory. On walking into the ward for the first time (just over a year ago) I was immediately transported back 30 years in time. It reminded me of a 'back ward' of old, large institutions, forgotten by the outside world. Fear and embarrassment greeted me, on the part of staff 'working' at making it work, sad indifference on the face of those who had lost hope, but stoned faced indifference is apparent, on the part of those instrumental in and enjoying the destructive power. I have had unconfirmed (and probably un-confirmable) but credible accounts concerning misadministration drugs and consuming patients food, neglect of patients basic needs, all of which go un-challenged out of this fear. This is the new 'flagship', Community Care, backup service to CMHT; Community Nursing and Social Care services. I would not want to Mental Health Section anyone into such an environment, even under the gravest emergency, nor insist, as a manager, that someone should have to continue to work there, or be required to transfer in, without significant commitment to substantial improvements. Patents and Carers who have tried the establishment tell me they will not go back under any circumstances. What a contrast this 'alternative' makes as compared with the ward that was closed. I am still lost for any clear, supported and consistent argument as to what the proposed benefits were supposed to be. I am still listening and watching for the transformation that would justify the closure and changes that were made. I watch Managers, who in many way I respect and appreciate their difficulties, providing a service at the 'expense' of genuine good practice and staff commitment beyond the call of their roles and responsibilities. If I did this while I was a Manager, I would have resigned in disgust with myself. The Consequence of Ward Closures and CMHT Staff reductions:Returning to the issue of the Ward that had been closed (and other reductions in services). This resource was so valuable that the Health Service Trust had invested in the PPP building of a new Community Hospital, incorporating this specialist 'Dementia' ward and the local CMHT. All looked promisingly progressive and effective, with a properly integrated service. Once the project had been completed and services & staff had transferred, the Trust then re-engaged in re-evaluations of it services in earnest. The CMHT gradually saw steady reductions of staffing, due to 'vacant posts', while the Trust still supposedly considered the future options for re-organisation of teams, etc. This delay in the decision continued, past deadline after deadline. A team of 12 became 6, then 5 (two part time) then just 3 available to work, with two of those periodically off with various stress related illness. Eventually the team was not viable and stress levels were affecting all remaining staff. Managers were notified and the team members were disbanded to other teams, to operate the same patch. When one of those other teams also started to show the same stress reactions, with manager taking sick leave, staff leaving in dissatisfaction, spasmodic management of the team becoming increasingly confrontational, inadequate and degrading, it was clear there was no adequate strategy in place. There were further effective staff reductions (because of dissatisfaction) and stress related leave. It was becoming increasingly clear there was a more serious problem underlying all our difficulties and distresses. Service waiting lists went up but were hidden by making them 'waiting lists' being managed by individual practitioner. These were, by their nature, increased active caseloads. Little account was taken of the previous years stress on the transferred staff. No induction was given to adjust the transfer into what was a clearly different and largely more restrictive style of management. Stresses for them also increased, along with the increased pressures on other members of the team, as available staffing diminished. A simple 'paperwork' error, with no risk to patients and which reflected a stress error on the part of two practitioners, resulted in the inappropriate, aggressive discipline of the more junior member who was in error. This was still pushed to disciplinary, in spite of acknowledgment of the error by the more senior practitioner. The more junior team member (who had worked at dramatically reduced staffing levels for over a year and had just taken some sick leave) was suspended in the usual insensitive way, in accordance with Policy. This person's caseload was transferred to the remaining depleted team members, on the same basis as the other caseload transfers, they were transferred on the 'personal waiting list' basis, but with expectation that they would be actioned within the first two weeks and then taken on ASAP. This was at a time when the team was recognised to be in crisis and where caseloads were agreed to be reduced, to bring them into line with what was realistically manageable. Notifications went out to line manager, from the team, about the risks to services and and to staff. The team was put in 'crisis' mode. Normal Referrals were suspended for a while and cases were dealt with on emergency basis. Within weeks there were dozens of emergencies and these were mostly real. Take away critical services and people go into crisis. There were no indications that staffing would be returned to normal levels and there was even talk that we may be considered to have been 'over staffed' compared with another 'less rurally dispersed' team !!! Stress levels were higher and the response from line manager was to continue with the same administrative duties as a 'high priority', ignoring the expressed concerns for risks and health to patients and staff. There were no adjustments to paperwork and administrative systems, although it was now impossible to follow them in the required time frames. Administrative support remained inadequate, especially given the increased administrative demands and the integration of two teams into one at a time of significant shortages of staff. The administrative workload actually increased because of PCT process changes and increased responsibilities and demands for assessment for Continuing Health Care. There were further, largely necessary changes, in the funding applications to the Local Authority. Services from this sector were becoming increasingly scarce adding to the teams workload. It was evident, to any intelligent observer, that the sums did not add up. Workloads meant that staff were again working into the early evening, trying to keep risks manageable, but often with increased stress on personal and professional lives, tolerable on a brief emergency basis, but this is over a two year, extended period for some team members, who had transferred from the previous depleted team. Good professional practice continued to clash with financial and geographical and professional boundary prerogatives. The gaps could not be ignored, professional responsibilities can not be ethically displaced. When they are, they became crises and become our 'bigger' problem for the immediate future. Most team members survived and professionally drove through the main tasks and met their professional obligations. They also introduced some managerial improvements that were necessary, in spite of the loss of their manager and the unreasonable stress levels affecting some of their health and personal lives. Administrative processes failed quite often and there are significant administrative backlogs but patients / clients were kept Disclosures of these facts was largely dismissed, polite grievances were not fully followed up and detailed accounts of the personal impact and effects were dismissed, in preference of summary accounts (which had already been supplied) and largely ignored in practical terms. Eventually, the time available to keep account of these shortfalls and consequences was just not available, neither was the motivation. This had to be done retrospectively, later. By shear determination, working on emergency basis, cutting corners and working outside time and practice parameters, the team survived until it was acknowledged the staffing levels needed improving. Even this process was sullied by persistent errors in advertising posts and implementing HR practices. After a little over a year the integrated team got a single full time, permanent professional. this was two year late for the old team. After between 18 - 2 years, we got 3 support workers replaced but still there is talk that the teams had been originally over staffed. Meanwhile, the CMHT's sister service (the Dementia Ward), backing up the direct Community work and from which the CMHT had become physically estranges, no longer had the same integrated support. The services in the ward clogged up and the respite service suffered, along with the speedy transfers to other services. Some of the important functionality of the services, provided by the Ward, became Within 2 years the ward was closed and the services nominally transferred to a community facility the other side of the county. The building is much older and in poor repair, staff moral is low and nursing practices inferior. Patients and their families have further to go for a service, the service offered is reduced and the number of beds in the district have been significantly reduced. The strong professional relationship between specialist ward and the CMHT has been lost and confidence of patients and families lost along with the move and resulting changes. This loss has put more pressure on the other Community Services, which are only able to make up the shortfall by extra costs that reflect the increased challenge of working with people in crisis. This cost is increasingly taken up by Community Service funding and progressively will fall to the PCT trying to make the savings. | Any Comments?: Email: Terry@visitweb.org Are you stuck in Overwhelm? All too often we 'put up with' and 'slog it out' when work gets too demanding. That is; when the work goes into 'overload, or, as the American's like to call it; a state of 'Overwhelm' (as distinct from the more pathetic state of 'Being Overwhelmed', where we can be identified as culpable in some ridiculous managerial way). It is usually in our nature, as professionals, to strive to meet our critical, 'person centred' obligations and objectives. These are not just those responsibilities as they are interpreted and laid down in Policy & Practice Guidelines (as our bosses would like us to accept. These, additional 'felt' and 'actual' obligation, include the Ethical and associated Legal obligations and the natural sense of responsibility we feel towards those we have been given some professional responsibility for; To ensure their security and personal wellbeing, appropriate to our defined roles. (See Note 'a' below) Clients come first and meeting the other demands of the Institution, even the 'unreasonable' ones, is part of the package which allows us to continue to meet Client needs. Where resources are adequate (if not perfect), this is usually possible without too much distress. It is worth noting, at this point, for reasons that will become evident later: Previous competent practice, without undue stress, is evidence of general employment competence. Areas of shortfall may have been identified and agreed, but our general practice is pretty well established as acceptable, within the first 3 - 6 months of employment. Unless formally determined as not the case. Now; there are times when there is an obligation to comment on how client's needs and risks are being compromised. This can be for various reasons. Ethical and Legal guidelines will largely determine when this is the case and Policy will help us identify when these situations have become critical. One of these times can be when your own and your colleagues, physical, psychological and emotional health is being affected by the workloads, frequent changes, harassment and other unacceptable conditions and factors of the employment. If practitioners are unacceptably stressed, to the point where functioning is inhibited, or if they are disempowered to the point that they are unable to fulfil their professional obligations, then clients can be put at unacceptable risk. It can be difficult, if you are also having personal difficulties (not unusual with work stresses), to identify what problems are due to personal life issues and which are due to unreasonable workloads. Which comes first is not critical, what is critical is to identify the excessive demands on workload at that time. Such circumstances have to be considered by responsible managers / employers. It is often useful to identify, where you can, when exceptional &/or unreasonable demands first started to be made on workloads. That noted, excessive & disabling demands and conditions should be reported through the established process within the organisation. It is important to do this early and to do so politely, without specific accusations. Lay down the facts and communicate them by Memo or eMail (cc them appropriately). Include the essential point of concern and support these with enough factual detail as to substantiate and discriminate between your various concerns. In the past, in many organisations, it may have been possible to have frank and open discussions about these employment workload issues. That time is now largely gone, but test it out. Cover yourself by ensuring that Managers, at each appropriate level, become aware of your growing concerns. Discuss these developing problems with Colleagues and get their perspectives also. Record incidents that arise from the ensuing pressures & distractions and report these to Managers. Keep everyone informed of the increasing risks to Clients, Carers, Self & Colleagues. This is as much a part of Health & Safety, as it is a requirement of professional ethics and good employee relations. Institutions and their Managers are under considerable pressure, financial, legal & administrative. They are unable to meet all the professional and institutional obligations with the resources that they have at their disposal. Some of these factors are beyond their control and some are due to the poor management of resources that they do have available. Manager, like ourselves, become defensive when they feel criticised, or accused. Often these deficits and contradictory requirements are beyond a Manager's control. This is an issue that may have to be taken higher, at a later stage. It is too easy for Employers to displace responsibilities onto us, using references to existing, often extensive, Policy Directives. It is not uncommon for the problems to be identify as shortfalls due to our inefficiencies & our neglect in following Policies. Managers are human and can do this in error, or as a prejudiced reactions to the induced work stresses of their own. Some are just bullies! Employers are now more inclined to seek to demonstrate general, or professional incompetence, once the persistent effects of these shortfalls have bitten into our confidence. Try not to let things get this far. Record and politely broadcast your concerns describe the impact of these on Clients, yourself & Colleagues. (See Note 'b' below) Your immediate Manager may be very reasonable, recognise the 'overwhelm' of workload and appreciate the unreasonable demands this places on upon you. It may even be possible to separate out and identify the contribution made by workload and personal issues. Some are competent to do this fairly. Often both are closely linked and the tendency is for the work to interfere in personal life. A good manager will adjust, or compromise the workload as best they can, to relieve the stresses, whatever the causes. If this problem is affecting other colleagues, this can become increasingly difficult, as it can place additional burdens upon them. Whether the problem can be resolved, or not (short term, or long term), it is important to record and report the difficulties and risks it produces, for your own and your clients safety and security. As the risks escalate, keep recording and politely informing Managers, escalating the level progressively. If you feel that there has also been a temporary impact on your 'competence', ensure that this effect is registered as consequential of unreasonable workload stresses. Accept any reasonable support to rectify and resolve these effects. No Blame, No Shame - live to the principle, even if others don't seem to have the courage. At some stage, where the deficits in resources are recognised as having a general effect, Senior Line Managers are usually called in. Their task is then to adjust team workloads, perhaps by temporarily restrictions on intake or, provide supplementary support for a time. They will also usually inform referring agencies of the crisis. If you take this gentle, determined approach you are likely to get your clients needs and risks addressed. Your own issues, and possibly those of colleagues should at least be partially met also. Such an approach generates trust in most instances, but there are never any guarantees. If your gentle approach fails to gain the respect of Managers it is important that you take a more formal line. This should remain polite and factual, well documented, argued and evidenced. It should carefully follow procedures and you are advised to get professional support from solicitors and unions, etc. For more details on dealing with employment issues, Workplace Bullying, Abuse and Dignity at Work issues, please refer to our other sections, follow our links and seek wide ranging advice from a number of quarters. Note 'a' Incumbent Ethical & Legal Responsibilities: These are Ethical and Legal obligation that Employers have to be aware of and accept into our on-going practice, when they choose to employ us. These do not need specifically stating, because they are an integral part of our registered, professional status, or otherwise legal requirement, place upon us in our employment, to disclose vulnerability and risks to clients / patients. These professional obligations and responsibilities are lodged with the GSCC, RCN, CSCI, GMC, other 'professional' registration bodies; incorporated into 'Codes of Practice'. In addition, there are more general professional / statutory organisations which state general professional duties and specific Legal & Ethical responsibilities, in more special circumstances. This does not mean that we are obliged to take these responsibilities directly on-board ourselves, but it does mean that we are required to take actions to ensure that the risks and needs are met adequately, by referring your professional concerns into the system appropriately. It is also reasonable that you seek to be informed what general actions are being taken to reduce the risks, and the approximate timescale involved. These broader ethical and legal responsibilities are not limited to those who are 'allocated' to us but also to anyone else we meet professionally, during the course of our work, and in many instances, that we become aware of in our more private lives. This is particularly the case with 'Children at Risk' and risks to 'Vulnerable Adults'. It is not enough that you are suspicious, or have an opinion, you have to be able to qualify and evidence your concerns. This said, the legislation and guidelines governing these issues is complex and beyond simple memorising. It is good professional practice to report all evidenced concerns that put clients and members of the community at risk. The Law is there as a safety net. It is not intended to replace good citizenship, excellent professional practice, or sound common sense. This is a mistake that Managers, as well as Professional, often make. Note 'b' Interlude:
I met my first distressing incident where a local authority worker had been targeted in this way, when I was about 10 year old.
I listen to the story he told my mother and was shocked at the level of his distress he expressed. He was clearly an intelligent and dedicated worker and gave his credible account well.
He described how he had identified irregularities in the practices in his Local Authority department. I won't go into details but he explained the progressive impact on the security of his position and the consequent affect on his general health.
This experience had a lasting effect upon my awareness of seriously bad management and institutional practices. I have never forgotten and have helped others in similar, bullying, incompetent management situations. Additional Commentary:
I have been around a lot and met some of the best Practitioners & Managers. I have also met some of the worst.
The best were variously qualified and unqualified Social Workers and Care Workers (along with other professional groups of course).
The worst were usually qualified - fact. They felt they had least to loose for being inept, judgmental & variously incompetent, I suppose.
Some of the very best were unqualified when I first met them. Some, like myself, either remained so, or had this thrust upon them :-). Here are a few stories of dedicated Social Work and Social Care practice. In good practice, it is almost impossible to distinguish between the two camps. We are none of us Radical, too proud to be associated with each other.  In the stages of preparation
Any Comments?: Email: Terry@visitweb.org NOTE: This Document is still at some stage of development. You are invited to respond and comment on its content and its logic. If you return to the document at a future date, you will be able to see its continued development, hopefully reflecting your own and others commentary. I thank you, in advance, for any contribution that you make. Please also feel free to visit and contribute, in any valid way, to these and other social issues, through our Forums. There is also a Chat Room and protected Chat Space for more serious group discussions and individual counselling. Please feel free o use this space for your legitimate activities. Copyright: Although you will see very few reference to other formal writings in this document, I acknowledge general recognition to the discussions and debates that I have had with students, practitioners and clients over the years. Most of the ideas and theory has evolved through this rather pragmatic process (operational research), rather than any formal reading. If any content of this document describes concepts, theory, or ideas that have been established else where, (prior to my writing, either here or else where - in part or in full), I acknowledge their entitlement to claim them as their intellectual property for financial purposes, if they can evidence this. I also reserve the right to retain them as my intellectual property, with due recognition to those who have made direct contributions, including other writers, should I identify such a past influences. Other than this, I invite you to share and copy any content, to the benefit of intellectual debate and the benefit of individuals and groups, without restriction, other than it be used for constructive purpose, in the wider context of my writing. Should you wish to use any material presented here 'as is', I ask that you then make reference to myself and the web site. The 'Reading Date' would be a useful 'publishing date' for the Current Edition. 1980 is the core publishing date for most of the basic ideas and theory (unless stated otherwise). This 'Reading Date' may be an important part of this 'reference', as the document (by its 'internet fluid' nature) will be constantly changing and this may affect meaning and interpretation, for those following up on such a reference at a later date. Thank you for your cooperation. TRC. eMail: terry.couchman@visitweb.org |
