As someone who has worked in the UK health service for close to 30 years (much as it pains me to be old enough for that to be even close to the truth) I can honestly say that things have changed beyond recognition. In 1980 I doubt anyone but those in the top positions had any idea of the costs of health care, and even then I do not know if anyone took any notice of how much was being spent. I expect there were always budgets, but as a lowly nurse they were of no concern of mine. If we needed equipment we ordered it. If a surgeon wanted to try a new procedure he was the boss and got on with it. The wards were clean (as far as I remember) and that cleaning was done by the cleaners who belonged to those wards. We also had a house keeper whose job it was to make sure we had all the equipment we needed and that the cleaners did what they were meant to do. At the same time though, as a student nurse cleaning beds after patients had vacated them was our job and weekends were often spent clearing out and cleaning cupboards. Hospital food left something to be desired, and in the hospital I trained at I would have given it a wide birth anyway given the probable state of the cockroach ridden kitchens (at that time hospitals were immune from health inspections due to crown immunity). Hand washing is a major thing these days, and rightly so. I remember learning how bugs are transmitted and remember washing my hands a lot. I also remember not doing dressings for an hour after ward cleaning had taken place and I remember learning how to perform a dressing using an aseptic technique. But I also remember the surgeon who took his gloves off to take a photo of the inside of someone’s body for his book and then put on new ones without so much as going near a sink. No one challenged this behaviour, he was a top surgeon and practically god.
In those days I doubt many people complained about anything. It was considered that everyone was working very hard, doing their best at all times and that all nurses were angels and doctors were special beings to be revered. If a patient was unfortunate enough to develop an infection no one considered that any of the staff were to blame, it was just one of those things. People often knew little of their condition and indeed asked few questions, particularly of the doctors who might have known the most. If they wanted to know anything they generally tackled the nurses for answers and were happy to be reassured that we knew best. That is not to say that everyone was happy with this, but of course we hardly ever asked what people thought of what we did and lived in the knowledge that if we had asked they would have been completely satisfied.
Now everyone is who works in health care is meant to know the cost of everything, is meant to know if what they are doing is effective both in terms of clinical and cost effectiveness. Patients expect us to keep them informed of everything about their diagnosis and treatment and if anything untoward happens it is pretty much going to be someone’s fault. The buzz words now are outcomes, key performance indicators and cost benefit. Those who provide patient care must ensure that they meet the outcomes, and that those outcomes can be measured. We are always asking patients what they think of our services and if we don’t ask they tell us through the means of local and national media, online forums and through letters to their MPs.
The way in which people perceive health care is important, and is something those of us working in the health service need to take account of. Because while I might be delivering all the outcomes my managers ask of me, and while I might be making sure I contribute to the reduction of infection rates by washing my hands and following universal precautions how do I know that patients perceive that I and others are doing all that they can? A report by the Healthcare Commission into the experiences of maternity services gives some insight into the gaps between policy and experience and between the perception of care at one hospital from another. For example:
26% reported being left alone during labour or shortly after giving birth at a time that worried them. This suggests midwives may not be adequately reassuring women when they have to leave the room – NICE guidelines say women should not be left alone except for short periods. Looking at labour alone, 9% of women at one trust said they were left alone at a time that worried them, while 33% said this at another. In 18 out of the 148 trusts, more than 20% of women said they were left alone during labour at a time that worried them.
8% of women said their hospital room or ward was “not very clean” or “not at all clean” while 18% said this of the toilets or bathrooms. At one trust 63% of women said the toilets and bathrooms were “not very clean” or “not at all clean”, while at other trusts only 4% of women said this.
This and other parts of the report demonstrate potential differences in the care women can expect in different hospitals but may also reflect expectations versus reality. If your midwife explains what is happening, and you feel reassured that you are safe with them then you are less likely to be concerned if you are left for a short period of time. If on the other hand she seems busy and rushed, doesn’t explain things to you and disappears without explanation then of course you are going to be anxious about being left. If your over all experience is good then the fact that the food could have been better might be less of a problem to you while if it was poor then this will add to your perception that the experience was poor.
The Health Service is a better place for wanting to control costs and wanting to improve the effectiveness of the care that is delivered within it. But we need to be mindful of the perceptions of our patients and as nurses and managers we can’t just assume that just because we are within budget and meeting the outcomes set by our boards and by government policy that our patients see it that way.