Around 20 years ago my father was admitted to a major teaching hospital in Wales. He was in his early 70’s and had heart failure. He was under the care of the ‘general medics’, on a general medical ward. He became mildly confused after admission, and within a couple of days had fallen in the bathroom, and was developing red areas on pressure points, a harbinger of pressure sores. I remember talking to one of the nurses, who was apologetic that there was no possibility of getting a suitable bed (‘there isn’t the money’), and that he had fallen when he should have been supervised. The poor nurse was literally run off her feet, a couple of nurses trying to cope with a score or more of patients. I was probably fairly cross, and not concealing it well—but so was she, reasonably so. She and I both knew how things could be made better. Both of us found it uncomfortable, because both knew that key decisions about care are usually made by people who don’t see patients, or have first hand knowledge of the ‘front-line’ (remember the Ballad of Reading Jail: prisons have walls, not so that convicts can’t escape, but so that God cannot see what goes on inside).
This episode came back to my mind when I read recently (not certain where) that NICE are going to come up recommendations for appropriate nursing levels on hospital wards. The background to this is the everyday experience that staffing levels in NHS hospitals are often inadequate, both in terms of delivering ‘medical care’ (however you define that) and as importantly, delivering ‘nursing care’ (as in the cliche: that nurse isn’t working efficiently…. she is talking to the patients….).
Now the idea that you need national guidelines or rules to tell you how many nurses you need on a ward tells you a lot about modern health care (and not just in the UK). But the debate tells you something about competing models of expertise. Some of those in favour of national ‘rules’, think this way, because they believe that without national ‘rules’ and audit of levels, hospitals cannot be trusted to staff wards appropriately. Essentially, that the people who run hospitals, are the ones who do their very best to avoid contact with patients or experience what the ‘front end’ feels like. And many of those who work in hospitals, do not trust the people who run them. Not uniformly, but far from being an exception, I suggest. Opponents of national ‘rules’, will argue that a myriad of local factors influence ‘safe’ levels of staffing, and that national rules will be inflexible, and will result in an inability to use staff to the best advantage of all patients. Neither argument can be dismissed.
In reality this is an example of the widespread conflict between bureaucratic control and clinical judgement. This is a topic that permeates the whole of modern medicine, and other professions such as law, too. It is one of the central challenges for anybody who thinks about how we educate future doctors, and the conflicts they will feel between answering patients honestly (as the nurse did), and being part of a health service that is threatened by medical or nursing professionalism.
Since wards nor staff are uniform widgets, local factors seem to me to be very important. Patients are not widgets too. The work required can be summarised in terms of statistics, but there will be variance around the mean. Some of this variation can be formally described, but much of it will be ‘soft’ and tacit. Many clinical skills are tacit: you don’t get to see them in an Excel spreadsheet. That is what you want your ward sister to be able to feel and measure, and make decisions accordingly. Indeed, these ‘meta’ skills seem to me to be so critical to her competence, that if she does not possess them, she shouldn’t be doing the job. You might try and make an argument that the ward sister, might not have access to all the information that is relevant, but this argument pales in comparison with the idea that those who have never seen the breakdown of patients and staff at any particular time, can made better decisions. So why not believe her?
I would suggest that there are only a limited number of explanations for why you would not want clinicians to make decisions about the level of staffing. The first is that they are incapable of doing so. As I have argued above, if a clinician cannot do this, it means you need to sack them, and appoint somebody competent.
The second is that you don’t trust them. That is you think they are self-serving—they just want an easy life etc. This would imply to me that the people who run hospitals do not trust their own clinical staff, in particular the clinical staff they appoint to be clinical leaders.
The third reason, might be that individual ward sisters, do not have the ‘strategic’ oversight needed to assess competing claims for staff on different units. Essentially, there has to be some rationing, and those not involved in direct patient care are in the best position to make such decisions. If you accept this argument, you have to accept that those not providing care, are better judges of care standards those those providing the care; and also that the global provision of staff across units is the correct one, and that the problem is merely one of allocation. To me, singularly unconvincing arguments.
So what do I think? Well, I think this is pretty easy. I do not think the central argument here is primarily about how to provide the best care, or even money. This is about the clash between medical and nursing professionalism (and what that means), and the need for a hierarchical bureaucracy to be in control. The money is important, but this is fundamentally about power, and a clash between corporatism and the modern model of a service industry, and clinical judgement. And the nurses at the University Hospital of Wales—and my father—were on the losing side. Orwell had it right: the more people extol the virtue of something, the less they care about it. The more people (including the GMC) talk about the importance of medical professionalism, the less attention anybody pays to it.