Saturday, 9 February 2013

Here's to your Health

On Monday last we got an update on the medical condition of Malala Yousufzai, who was shot in the head by the Taliban for the crime of encouraging female education. What a truly remarkable young woman.

But, much as we admired her bravery there was also something else to admire; the care she had received in a British NHS Hospital. As her doctors talked of the treatment they had given we marvelled at their skill, and we all also at least silently smiled as Malala herself talked about how those who had initially saved her life and then looked after her through her remarkable recovery had also become her friends.

And at that point we also all felt a sense of pride. This was our NHS, albeit on this occasion treating an exceptionally deserving foreigner*. As good as anything available anywhere in the world and available to any one of us free of charge should we, God forbid, suffer a similar trauma.

And that of course is how we like to see the NHS; involving state of the art, life saving, treatment delivered by universally brilliant and brilliantly dedicated staff. Only it is not the reality.

I am 54. I am far from a particularly "healthy lifestyle" person but in my entire life I have spent four nights in hospital. One night when I had my tonsils out when I was a very wee boy (although I still remember the free ice lolly) and three as an adult before and after the removal of my appendix (ice lolly not provided).

That, I suspect, is pretty typical of people of my age.

I go every so often with minor (to them if not to me) complaints to my family doctor and I am never less than satisfied with my "treatment", even if it consists of nothing more than reassuring me that I am in less danger of imminent expiry than I am maintaining myself to be.

My own personal experience is typical. Unless you are unlucky, you don't have much to do with hospital treatment during your working life.

That awaits retirement. For the average age of an NHS hospital in-patient is over seventy.

Now, albeit that I like to think that I have avoided a mid-life crisis  when you get to your mid fifties you do start to think how you would like to go.

For me, I imagine it would be on my eightieth birthday (I'm not (that) greedy). Just as, on 10th September, the Summer was coming to an end. I'd be living in my retirement house overlooking the sea somewhere between Bari and Brindisi and have enjoyed a long lunch in the open air in the company of all my favourite nephews and nieces; their children and ideally the first of their grandchildren. After lunch we'd have slept, then gone for a swim, and they'd have then announced they were going out for the night but I'd have protested I wasn't getting any younger.

So, I'd be sitting overlooking the Adriatic, as the sun set in the hills behind me, listening to the last act of the Marriage of Figaro, and enjoying a coffee and an Averna (or perhaps more than one on this occasion). And I'd be thinking that I must make more coffee before the others came home but that first I might have another little snooze......................

Only it never ends like that.

Most often, it ends in pain and incontinence and mental confusion. Among strangers and, most often, in midwinter. That's the real world.

And that is, on any view, where the NHS is failing.

I was prompted to write on this subject by an exchange on twitter mid week about the publication of the latest stage of the Francis report into the failures of  Stafford Hospital. Inevitably, almost immediately, some mad cybernat appeared to assert that this was just an English problem but I was struck by how quickly that was disputed by those of all political persuasions who joined the discussion. Nor, for the avoidance of any doubt is/was it a problem of the Tories making, or a problem created by inadequate resources. All of these events happened while Labour was in power and while NHS spending was at record levels.

Unfortunately, the problems go much more deep than that and had no single cause.

One of the causes however is that undoubtedly the balance in the health service has been and continues to be got wrong between the interests of the staff and the interests of the patients. The reason that professional medical staff, doctors and nurses and the rest, have historically enjoyed such deference is the belief that they undertake not a job but a vocation. But it is they themselves, when it has come to their terms and conditions, who have insisted that, when it suits them (early retirement, the right to public holidays, regular working hours timed to the minute) they be treated just like any other in-demand skilled "worker". And if that affects the care of patients too bad. I say when it suits them because there is of course one huge exception to their wish to be treated like other workers and that's when it comes to being hired or fired. No matter what failures of management took place at Mid-Staffs it was not the administrators who directly neglected the patients and yet even those calling for heads to roll are inclined to focus their demands on the management alone. I have to say I cannot see why the buck should rest exclusively there.

Then again, it hasn't of course rested even there. Despite the well documented tales of treatment worthy of Dante's inferno; despite the (at least) hundreds of unnecessary deaths; despite the four year public inquiry at, no doubt, very considerable public expense in itself; despite the fact that the hospital's A&E Department has had to be closed because no-one wants the stigma of having worked there on their CV and that rumours abound that the entire hospital may soon suffer the same  fate. Despite all of that,  NOT ONE SINGLE PERSON HAS LOST THEIR JOB. That's right, not one.

I won't even start on the fact that many of those involved have actually been promoted.

And, of course, in Scotland, we don't even have the option of dealing with under-performance through selection for redundancy. For the no compulsory redundancies policy leaves us bizarrely offering enhanced settlements to bribe to depart those who will easily secure a position elsewhere while those otherwise unemployable are entitled to sit tight. Where is the interest of the public in that arrangement? Indeed where is the interest of the public in so much that passes for personnel management across the Health Service?

And that brings me to the politicians. They, all of them, seem to feel an obligation to take the responsibility for failure upon themselves and whoever is in Government seems to feel the obligation to deny, in public at least, that they are aware of any problems unless they are completely unignorable.

Cameron was right to promise last week to do everything possible to prevent a future Mid Staffs but he also felt it incumbent on himself to apologise. Why? He wasn't even in power at the time and, even in respect of those who were, no-one suggested that what happened was anything (lack of funds or lack of proper management structures) that might reasonably be laid at the door of the politicians.

We had a similar if less serious example here in Scotland last year. When Jackie Baillie challenged Eck about the lack of blankets at Paisley's RAH, his immediate reaction was to deny it. Why, again I ask? He knew, presumably, that Nicola hadn't raided the blanket budget to spend on a free Saltire for every patient, so if there was an allegation of a shortage of blankets (as it transpired there was) why couldn't he just say he'd look into it? If true, no matter who's fault that was, it wasn't going to be that of him or his administration. But he (and a Labour FM would, I suspect, have reacted similarly) started from the assumption that, in respect of any supposed criticism of the NHS, they needed to defend, or at least deny, the indefensible.

We need a political class more prepared to put some degree of objectivity into their strategic direction of the NHS. I repeat myself;  if they provide the funds and the structure, then individual front line failures are no more their responsibility than it is their responsibility to carry out tonsillectomies. Crucially, once they realise that it frees them to be more critical of these front line failures rather than acting as uncritical cheerleaders for the Service as a whole.

It is inconceivable that the local MPs were unaware of the problems at Mid-Staffs but it simply is not the done thing for a local MP to criticise a local hospital. Again, the question is why?

But there is also one other, final, thing that needs to be said about Mid-Staffs. Maybe it was indicative of the fact that in the care of the very elderly with advanced dementia we are trying to do the impossible.

Modern medical science has become very good at keeping people alive but we haven't really come to terms with the consequences of that. And I really do wonder if we have got the balance correct in that process between "treatment" and care.

This is astonishingly difficult territory but I do wonder if the priority between the preservation of life at all cost and the assurance, in so far as possible, of comfort and familiarity at the end needs to be revisited. None of that remotely excuses the horrific events of Mid Staffs (and if you read the earlier, factual, report, some, no much, of what happened is truly horrific) but it cannot be denied that it was the context in which much of it occurred. And it was the context of the experience of many of my twitter correspondents.

There are reasons that many terminally ill but mentally competent patients choose to die in their own homes in the knowledge that it might mean the very end would arrive somewhat sooner; just as there are reasons some pregnant women opt for a home delivery even though the risks to them and their baby might be very slightly higher.

Yet, in this context, many patients with dementia do not get to exercise that choice. So they end up in an unfamiliar environment, among strangers and by the very nature of their condition they then make "unreasonable" demands on the time and patience of staff. And that's before the impact on other patients is considered.

And the cottage hospitals are increasingly closed, at the initiative not of the patients or their families but rather to meet the working preferences of the medical professions I have referred to above. Worse still, that preference is sometimes disguised as being "medically" justified.

Jackie Baillie had a plan for a National Care Service to merge the current functions of the NHS and Social Work in this area. Whether that will ever happen I doubt, for public sector reform has not been one of the Scottish Parliament's strengths under any administration, but that this is an issue that will only grow with time is something that cannot easily be ignored. We might not yet have had a Stafford Hospital in Scotland but I use the word yet advisedly. And if any single person reading this can't name at least one NHS Hospital in Scotland where they would not want to be an elderly patient then they're speaking "in terms of the debate".

*I should say that her treatment was paid for by the Government of Pakistan


  1. Excellent ; makes powerful arguments for ...something... but I'm not sure what [ and I guess neither are you ] . I'm trying to get some thoughts on screen about this known tragedy and similar , in all parts of the UK, and over a longish recorded timescale

  2. A great start, Ian, and a lot more to be said here. The debate needs to be had re NHS and how it operates but particularly how we care for our elderly. When I was growing up (in a Catholic upbringing) people argued against euthanasia on the grounds that deciding when people die is God's will. The extension of life is equally ethically problematic - should we prolong life at all costs? Who is this good for? The recipients of care? Their loved ones?
    It is rapidly becoming one of the major policy issues we need to address.

  3. Most of the time what the patient do is increase their cloths to prevent the increasing of temperature.