28 February 2013

Personal reflections post Francis

Yesterday, I attended a one-day conference on the Mid Staffordshire Report at the King's Fund. Listening to Robert Francis, I was reminded of an incident that took place many years ago when I worked as a speech and language therapist in a hospital unit providing care for the elderly. The incident concerned a lady who had a stroke, resulting in some weakness on her left side. She had severe difficulties expressing herself, although her understanding of language was unaffected. She knew exactly what was going on and what was said to her. She did not appear to have many visitors, but was always pleased to see me and was very motivated to work to regain her speech.

The enduring and disturbing memory triggered by Francis was of coming to her bedside, to find her distressed, agitated and unable to speak, gesturing frantically to me, pointing to her bed. Her sheets were wet and soiled. I got her out of bed and helped her to sit on the chair. I told her I would go and find help. I went to the nursing station; there was no one there. There appeared to be no one around. I eventually found a nurse and told her what had happened. She looked blankly at me. She said: “I'm the only one here. Everyone else is on a tea break.” I said: “Where are the sheets? Can I change Mrs W?” “No,” she said. “It's not your job.” “But she is very distressed,” I persisted. “She will have to wait until the others come back.” “No,” I said. “She needs help now.” I went back to Mrs W and explained that there were very few nurses about. “I know!” she cried.

For several days afterwards, she was subdued, tired easily and was less motivated to work on her speech. I spoke to colleagues about the incident. I felt there was something wrong with a system that could not respond to distress, still less find it acceptable that a speech and language therapist was interfering in the care of a patient. I don't know how typical this was at the time, of course. Nevertheless, in my view, this should not have happened.

Since those days in the early 1980s, the NHS has gone through at least a dozen re-organisations, as well as witnessing a few major inquiries. Sadly, the same themes recur. From patients, those themes are poor care, not enough staff, not knowing what is happening to them, and lack of involvement in decision making. At worst, they are about neglect, rudeness, and lack of respect from staff. What do staff say? Staff shortages, lack of management support, poor supervision, feelings of disempowerment and disconnection. I have often heard front-line nursing staff say they are too overworked and understaffed to be able to afford the luxury of talking with their patients. Too many demands lead to emotional shut down and apparent lack of compassion.

Francis highlighted for all of us involved in delivering health care that a positive culture and clear lines of accountability are not optional extras. They are fundamental to good care. One element necessary to create and sustain both of these is for professionals to have and maintain a clear sense of purpose and a shared set of values that drive everything they do. Some would call this the heart of professionalism. HCPC has been working over the last few years on a programme of research looking specifically at professionalism. We have known for some time that the majority of complaints are about conduct not technical competence. We wanted to address this, initially through research, and later through dissemination and debate with clinicians, educators and students, as well as within the regulatory community. We published the first report in 2011 and the second will come out in 2015. The wider questions we have posed for those on our Register are: What does being professional mean to you? What do you do if you see unprofessional behaviour in others? Can you have a conversation about difficult things, like being a witness to poor care? How is professionalism learned? How do you cope with the stress of being a professional caregiver, working daily with vulnerable people, dealing with unforeseen illness, disability, distress and uncertainty?

Nothing in the Francis report or in today's discussions leads me to think we need to do less. In fact, stepping up our call to registrants to deal constructively with these difficult issues seems all the more relevant in light of this report. We will be looking closely at our responsibilities as a professional regulator, what more we can contribute, and what needs to change in our standards and our engagement with other agencies. Whatever re-organisation the health service undergoes in the coming months and years, it must not lose sight of the need to address the fundamental commitment to care, which we know is not universally delivered, still less universally understood. In the words of Francis: "Every single person serving patients must contribute to a safer, committed and compassionate and caring service."

This is not just about doctors and nurses. If we do not act collectively, we are all undone.

Anna van der Gaag
28 February 2013