Wednesday, 16 February 2011

The NHS: fragmented care

The broadcast media yesterday were full of coverage of a report about the quality of care given to elderly people in the National Health Service.
The NHS is failing to treat elderly patients in England with care, dignity and respect, an official report says.

The Health Service Ombudsman came to the conclusion after carrying out an in-depth review of 10 cases.
The BBC News website report can be found here. The news release from the Health Service Ombudsman is here; the full text of the report is here.

It was interesting to listen to much of the coverage, and to read a blog post (and its comments) such as this one by Fr Ray. Much was said about nursing staff, their training and their need to be more caring. But two things struck me.

The first is perhaps the less significant one in terms of the daily practice on hospital wards or in GP's surgeries. And that is that a culture in which euthanasia, and/or the idea that living at the end of your life when you are ill is something that is unwelcome and to be avoided, are entertained as a legitimate options of thought and practice - such a culture has a deep rooted ambivalence about the care given to elderly patients. It will not be that there is a definite attitude of "we should not care" about the elderly, more that, at the level of culture, there will be a hesitation about it. How far this affects health care practitioners in their day-to-day work is difficult to assess but it does have a presence in the culture.

The second is much more significant in terms of daily practice on hospital wards. This is the phenomenon that I have come to think of as "fragmented care". On a typical NHS ward, qualified nurses (and perhaps student nurses on placement) are responsible for providing clinical aspects of care to patients - dispensing drugs, inserting IV lines, changing dressings etc. Health care assistants are responsible for things like washing patients, making them comfortable, changing beds and the like. They now take and record patient observations (temperature, blood pressure, blood oxygenation), though they do not make clinical decisions based on those observations. Patient meals can be the responsibility of the staff of a third party provider in addition to this. Whilst specialist aspects of patient care - physiotherapy, occupational therapy - have often been provided by people with those specialist skills, I think there is now more than in the past the provision of different components of patient care on a ward by different people. "Fragmented care".

At one level, this is purely a question of organising how the work is carried out, and, provided that the work is well organised and carried out conscientiously, it is not to the disadvantage of the patient. But I think it does also have an implicit ethical component. Clinical care is separated from personal care, the technical/skilled care from the care of the person - the realm of the nurse from that of the health care assistant. In some of the experiences related in the Ombudsman's report and in the media coverage this has been expressed as "That's not my job". The care due to the person of the patient, though, is a single phenomenon of care - so that the care that a nurse gives when setting up an IV drip or an oxygen mask is at one with that given by the health care assistant who washes the patient in the morning. If the care is truly to be the care for a person, rather than just the care for a body, then this unity of the phenomenon of care needs to be recognised and practised.

Clearly, it will never be possible for all the care provided to a patient in hospital to be given by one person, and that is not something that would be sensible to ask for. But the structural separation of "clinical care" from "personal care" is perhaps something that should be reversed or overcome. It would appear from the Ombudsman's report that elderly patients would be particular beneficiaries of such a change.

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