Former NHS Nurse and manager now contemplating the NHS from outside

Archive for the ‘Maternity’ Category

Patient involvement in the new NHS

My last two jobs have heavily emphasised the involvement of patients in healthcare. When I was commissioning maternity services, those patients were called women and now in the world of cancer they choose patients and carers over the more common term ‘users’. Both of these areas of healthcare have, for many years placed the experience of patients using their services at the centre of planning and delivery of services. At times those involved have felt that professionals pay lip service to this prescribed requirement. But I know that my senior midwifery and nursing colleagues have taken their role seriously as have I. Putting what is discussed in meetings into practice can be difficult as real events take over and people struggle with the realities of their job.

Most of the NHS Trusts (providers) have specific Patient and Public Involvement committees and groups, but these are not specific to a single condition or disease. Maternity is definitely different from the mainstream, given that in the main pregnant women are not ill and are not patients as such. Cancer (rightly or wrongly) also considers itself to be different with unique needs.  Peer review measures for User Involvement require us to have a User Partnership within the Cancer Network, laying down a number of ‘measures’ relating to both the experience of patients and the involvement of service users and carers in services.

The new NHS throws all that we know about this kind of service (or disease) specific involvement will take place. I have had the pleasure of working with some amazing people in both areas over the years. They work hard, give up so much of their own time, often in conjunction with running their own busy lives. Sometimes in the case of my current user colleagues, they continue to manage the after effects of cancer or to battle recurrences of ill-health. They are not surprisingly a little anxious of what will become of their efforts once PCTs (who have been statutory expected to manage Maternity Services Liaison Groups) have been abolished and Cancer Networks have been subsumed into Strategic Clinical Networks.

Will the clinical networks be able to support real patient involvement within the entirety of their portfolio (cancer, maternity, children, mental health, stroke etc etc). Or will it be left to the NHS Trust, CCG and other more general Public and Patient Involvement groups to pick up the mantle. Will the stalwarts of maternity and cancer involvement join in with them, will some of them who are part of the Links mechanism become part of the Health and Well being Boards. Does it matter if this is about general patient experience and involvement or should their be something special for specific groups. Or will we lose something from all of this and will some of those committed individuals walk away. From some of what I have heard, many are disgruntled and hurt that the work they have done so far will apparently be lost, and they might just.

Increased choice? Unsustainable demand?

Politicians of all colours are now very keen to offer us increased choice in healthcare. There is an assumption that if you can choose to ‘buy’ your healthcare from anywhere you like then this will lead to the best becoming better and if a provider is not good enough then they will see that they need to improve or else suffer the consequences.

Choice, or perceptions of the ability to choose have been evident in education for some years. The schools that have been perceived to be ‘good’ are over subscribed, they are staffed by excellent teachers and people move house to be able to send their children to them. In some areas, where people are particularly mobile and affluent this may be the case. In healthcare choice in relation to maternity has been a particularly popular phenomenon with some people. Choice of the place you have your baby, whether this is home, a midwife led unit or obstetrics unit, or whether it is about choosing one hospital provider over another is very important to some people. Exercising choice can be a tricky thing. For one thing you have to know what choices are available, and in maternity you have to understand something of your own level of risk in exercising that choice. Perhaps your pregnancy is medically or socially risky when it comes to making some of those choices, perhaps you don’t have the means to travel 30 miles to a chosen different hospital. Perhaps also the services in your area struggle to attract the right mix of skilled staff, not because they are providing a poor service but because they are geographically situated close to an area where staff can attract higher pay.

If you are pregnant, then one thing is sure you will need some kind of maternity service, and it will be the duty of your local healthcare commissioners to make sure you can access it safely. Those commissioner will be required to make sure that the maternity services offered are safe, adequately staffed and that those staff are appropriately qualified to fulfill their role. Maternity Matters gave us a role in promoting choice and in making sure that those choices were available and that people were assisted in making those choices. When though does choice become a want or a demand? When does choice and the way it is exercised by the few mean that those who are more able to move, more affluent, more able to make choices have a detrimental impact on the many?

As a nurse working in a PCT I am obliged to take part in one of the much maligned prior approval schemes that are popping up all over the place to manage the demand for healthcare. ‘Low priority’ treatments such as removal of  non cancerous skin lesions and varicose vein surgery are judged against a set of criteria set by a panel of doctors and approval is given or not for surgery to take place. What strikes me most about the way in which cases are presented is the extent to which GPs and surgeons struggle to tell patients that their problems don’t quite meet the criteria. Often they will write that the patients ‘wants this surgery performed’, and I am left wondering; yes, but do you think it needs to be performed.

I had the pleasure of setting up a new nurse led service a few years ago for people with rheumatoid arthritis. My job was to manage the day-to-day issues that arose for patients coping with a long-term illness, while taking potentially lethal drugs and still needing to deal with normal life. We set up a great service with a help line, monitoring clinics, home visits etc. What it taught me though was that where you create choice and opportunity you will also create demand and to a certain extent want. The people who shout loudest will often if you are not careful get the biggest share of what is on offer and that may be to the detriment of those who cannot shout and indeed may not even know what to say.

Whoever is in charge, whoever does the work of commissioning or buying healthcare, whoever provides it, there will never be enough of it to go around if someone doesn’t take the responsibility for making sure that decisions aren’t only made because of what is wanted, where it is wanted and whom it is wanted from. That of course is what makes my job interesting if not tricky!

Promoting bigoted views

I am not really a fan of radio phone in programmes. This is not because I don’t think people shouldn’t be able to enter into a discussion about current affairs on a media forum, but it is because they seem to encourage narrow minded views to be expressed. This lunch time I happened to be travelling to a meeting when Jeremy Vine was discussing the idea, apparently promoted by NICE that pregnant teenagers should receive their antenatal care in school. The usual formula was followed, firstly he introduced a couple of ‘experts’, in this case a policy expert and the Chief Executive of the National Childbirth Trust. This was followed by a series of phone calls, emails and texts from listeners. I only caught a small amount of the first part, but while both speakers expressed some interesting and reasonably balanced views actually where was the real patient expert? Where also was the voice of the teenage pregnancy midwife?

What was worse however was what followed; a flow of old fashioned views and opinions which essentially said that teenagers who became pregnant should be separated from their peers for fear that their loose ways could be caught. It was also stated that young mums tend to be scroungers who sit together smoking and generally getting up to no good.

I have had the pleasure to meet and work with a number of people who work with young people who become pregnant. I know that these are people who specialise in helping and supporting young women, their partners and families through pregnancy and beyond. I have been told that school is not always the best place for clinics and that seeing young people in more neutral settings away from the older clientèle works. I also know that in most areas in the UK any individual school is unlikely to have more than 1 pregnant teenager at any time.

I welcome NICE bringing up the issue of vulnerable pregnant women including teenagers, but wonder quite how some of our media outlets come up with their ideas around what makes balanced and informative broadcasting. Jeremy Vine’s first email on the subject was from a woman who suggested that pregnant teenagers should be given a good thrashing; I am sorry but that is neither balanced and informative.

1997-2010 what has changed?

In 1997 I was a proper nurse; well a nurse seeing patients. My head was firmly down and the work was hard; my patients had rheumatoid arthritis. My job essentially was to start them on heavy duty medication for their disease, monitor their progress on that medication and to provide advice and support. It was a good time for me, I was competent at my job and the work while busy didn’t overwhelm me. The medications we used was reasonably tried and tested and the new wave of drugs now used to treat this disease hadn’t arrived to test our budgets. The internet was reasonably in its infancy, and the main source of healthcare advice for patients came from the written rather than the virtual media.

My main source of learning around that time related to things clinical. I studied for a qualification which allowed me to perform joint injections. But really I had little need for government policy. It wasn’t until I decided to change jobs in the autumn of 2001 that I was required to even understand government policy. This didn’t make  me a bad nurse, just a nurse doing her job in the environment within which she needed to work.

Jump forward to 2010. Now my job is about commissioning health services. It is about making sure that the services which are provided for the local population not only meet their needs but are of the quality that  local and national policy tells us they should be. We now have the National Institute for Clinical Excellence to give us clinical guidance and we have the Care Quality Commission to monitor standards. For someone commissioning maternity services we have Maternity Matters (about choice and quality). We also have a public who know what they want, know what they are entitled to and know where to look for evidence that they are not getting it. Policy is now important.

Imagine then a day where one Prime Minister causes East Enders to be cancelled and another arrives. Imagine a day where DH staff are told that policy is suspended while it is decided what the policy for health now is.

Over the last week I have wished I was back with my patients; trouble is, can a nurse in 2010 ignore policy and keep her head down?

If you were going to name a new form of flu what would you call it?

swine2I am pretty sure that if I entered a competition, to name a new form of pandemic flu, first prize a trip to Mexico my answer wouldn’t be ‘Swine’. But I guess that I  might not have forseen the involvement of the pig, so what do I know? The media here are loving this. Yes they would deny it, but if you can put on your front page that 750,000 people are likely to die, why be realistic? I travelled today on a train to London, no one wore facemasks, but then no one sneezed. I spent several minutes myself (currently suffering from hay fever) wanting to sneeze, but fearing panic dared not. Even if I had a tissue handy I had no where to wash my hands or dispose of my tissue and what is for sure I don’ t want to be thrown off a speeding train.

I am not trying to make light of this whole thing, since people have died and it is pretty worrying to those directly involved. However, I think the hysteria misleads and detracts from the seriousness of the situation. Plus please don’t let my reintroduction to clinical nursing be at the sharp end of a surgical mask dishing out antivirals!!!

The picure above particularly fits as my day in london was about a commissioning strategy for breastfeeding. Did you know that breast fed babies are more likely to be healthy and less likely to be obese? No? Well thats cos it is less interesting than a flu from Mexico caused by pigs and called Swine!!

So it is April

aprilfoolWe have emerged from winter, it is officially spring and it is also, since last weekend, British Summer Time (which reminds me that I need to reset my blog’s clock)! I seem to have lapsed in many ways during the winter, I have allowed myself to put on weight, and must sort myself out if my new summer clothes are not too small before I even buy them (and no I won’t be buying any kind of bigger size). I have become lazy when it comes to my blog, and haven’t really written anything particualrly interesting about my own life, or the job I do for ages. 3 or 4 posts written over the course of that time have pushed my traffic up massively, but I am not sure anyone would return to read my blog until I buck myself up. I also need to get myself doing more things outside of work, with a son hopefully going to university in the autumn I surely need to get  myself something more interesting to do than sitting on the sofa reading a book or watching TV. I need to get out more, I need to explore the environment more and I need to get more active. I also still wonder if I shouldn’t be looking for a new job, and indeed have one eye on the jobs market. Work though is really busy, commissioning has become quite a lot more interesting because actually we now have to do more in the way of managing performance and in turn we are being performance managed much more by the Strategic Health Authority. Maternity is an interesting area to be working with, since it is pretty high profile, there are targets to meet and those who use the service are not backwards in coming forwards if they are dissatisfied with what is on offer.

I know I’ve said it before, but this time I mean it; During April I am going to post daily. I am going to talk about my struggle with food, because I do struggle not to eat things I shouldn’t. I am going to talk about wine, because I think I like the taste of it too much and sometimes use it as either a reward for things going well or as some kind of treat when things have gone less well. I am going to try and talk about work, though as I have said before this is less easy when you are the only person doing a job in the whole county. But I am going to try. I also have somethings to say about how it feels to be a middle aged mother whose only child is going to leave home this year and who is going to need to learn about being a wife in a home with no children again. So here goes, this is April 1, you are no fool and neither am I!

The NHS long hours culture – a system running on goodwill

nurseThe other day I sat next to a senior midwife who told me that none of her fulltime staff is under 45 years of age. The younger midwives find fulltime work too tiring. Another told me that she was at the conference in her own time, and that midwives who want to attend a function I am organising in a couple of weeks will need to do so on their days off. The midwife establishment and staffing levels just don’t allow for much in the way of release for training, sickness or days off. On Thursday I needed to speak to a local Head of Midwifery, her PA told me that she was on annual leave, she had been into the unit that morning till 11am but had gone home now (it was about 1pm at the time). Nurses who blog on the internet also describe a long hours culture, one where people take no breaks and hardly have time for a glass of water or trip to the toilet in 12 hours. Even within the office environment it is considered more important to meet your deadlines than anything else even if meeting that deadline means staying till 6pm or more likely taking the work home and spending your evenings or weekends doing the work.

I am pretty sure that the individuals working long hours in the NHS do so without particuarly being TOLD to stay behind, to work in their own time, but it becomes an unwritten rule it becomes part of the culture. One where if you don’t work in the same way as those around you then you won’t fit in, maybe the opportunities for promotion won’t occur and maybe that promotion would just involve even greater long hours working. What happens if the responsibilities you have outside of the workplace mean you actually need to leave on time? What happens if you have a medical condition that means missing meals or fluid are detrimental to your health?

Yesterday I visited my husband’s elderly granny in a hospital not far from here. The ward was full of elderly ladies, most of whom looked as if they had high levels of dependency. When we arrived her IV had tissued, the nurses came to her speedily, they took her observations, made adjustements to her care and detected that she was becoming hypothermic and acted accordingly. While this was going on, I saw only one other member of nursing staff on the ward. The care seemed to be good but I have to wonder about the pressure the staff are under on that ward. I came away, as I often do, wondering if I shouldn’t get back into clinical practice and do some shifts on a unit like this. Trouble is, my working week is pretty intense as it is. I have deadlines to meet, I can’t take breaks, though because I am desk (or meeting bound) there are opportunities for food and drink to be consumed. When I get home I am tired and sometimes there is work still to be done. Why on earth would I work extra in those kinds of conditions when I could be at home ironing and cleaning?

If the NHS pretty much functions on goodwill, what then will happen if that goodwill runs out?

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