The person in the patient

Age UK, the leading charity for older people, has recently published their report ‘Still Hungry to be Heard’, which found that an unacceptable number of older people are becoming malnourished when they are in hospital. The accompanying research also found that nearly a third of nurses are not confident that it would be noticed if a relative of theirs was malnourished when entering hospital.

The word ‘nurse’ derives in part from the Latin word ‘nutricius’, which means “that which nourishes or suckles”. The provision of food and water in hospital would be considered by most to be the basic expectation of care; indeed a fundamental human right. So it is all the more alarming to hear that people are becoming malnourished during their stay in hospital.

The report recommends that there are seven steps to end malnutrition in hospital, which are the responsibility of both professionals and institutions. Step 4 recommends that patients are weighed on admission, while Step 6 recommends the use of a red tray system to identify those people who need help at mealtimes. These are very useful, practical recommendations that hospitals might introduce almost immediately.

Step 3, in contrast, states that hospital staff must follow their own professional codes and guidance from other bodies. Whilst less specific, in our view this recommendation is potentially of most significance. The Nursing and Midwifery Council’s Code states that nurses must ‘make the care of people your first concern, treating them as individuals and respecting their dignity’. The other regulators have similar broad requirements of their registrants, many of whom are equally responsible for ensuring that patients on hospital wards are nourished appropriately.

It is these high level principles of human compassion and respect for others which help to ensure that people receive care that is appropriate to them, and which respects their dignity. Specific recommendations are extremely valuable, but cannot succeed in the absence of compassionate health professionals. This is a topic we discussed in our last Viewpoint article.

The notion of compassion is addressed in a recent King’s Fund article, following the very moving and personal article by Dr Kieran Sweeney, written shortly before his death from the asbestos-related cancer mesothelioma in December 2009. In it, he noted that the care and treatment he received was ‘technically impeccable’, but the relational aspects lacked strong leadership and were often insensitive. Such accounts merely reinforce the importance of health professionals seeing the person in the patient, a quality that supersedes what is written in any code or guidance.

John Illingworth

Policy Analyst

You can watch the interview with Dr Kieran Sweeney, sharing his experience of care and interactions with health professionals on the e-learning for healthcare website

Commenting on the announcement Harry Cayton, Chief Executive at CHRE said: “We look forward to working with the Department, the regulators and with patients and the public in determining the detail of these proposals.”

http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117844

Regulating for compassion

There is a common theme in recent healthcare scandals: the failure of compassion. There are frequent references in the report into Mid-Staffordshire NHS Foundation Trust to care which lacked compassion, and to its importance. Compassion is one of the NHS-wide values in the NHS Constitution. The importance of compassionate care is stressed repeatedly in the recent report of the Prime Minister’s Commission on the Future of the Nursing and Midwifery in England, Front Line Care, which found that ’compassionate care is competent care‘ and reports that ’service users and the public told us that above all else they wanted nurses and midwives to be caring and compassionate’. More recently, Transparency in Outcomes, one of the consultations flowing from the White Paper Liberating the NHS, states that ‘Quality of care includes the quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated’.

Promoting compassionate care opens up difficult territory for regulation. Clearly, health professionals cannot ‘suffer with’ their patients – the true meaning of compassion – or they would be unable to get through the day. Neither should they be glacial and emotionally distant. How should regulators define that optimum desirable state between these two extremes?

A further difficulty is that compassion implies an intimacy which sits uneasily with health professionals’ obligations to preserve clear personal and sexual boundaries between themselves and their patients. While some patients may welcome a more openly compassionate and expressive approach, others may not wish to engage at this level with health professionals at all, preferring a greater distance to be preserved.

Despite these difficulties, can regulators promote compassion in the sense of instil it where it is lacking? There is some research evidence to suggest that teaching compassion is possible. One study found that where subjects were exposed to compassion-inducing stimuli such as the sound of crying, meditation could heighten activity in the area of the brain associated with compassion. Other research has shown that working in an environment which is demonstrably compassionate and encourages students to pursue cases in which they become involved encourages greater compassion.

However, a more pragmatic approach for regulators might be to concern themselves with conduct and behaviour, rather than trying to influence personal motivations. Conduct and behaviour can be measured, evaluated and assessed in the circumstances in which it took place. Regulators can promote examples and guidance on what constitutes acceptably compassionate behaviour.

Regulators also need to be wise enough to regulate with compassion: to treat regulated professionals with sensitivity and care, in particular those facing allegations of unfitness to practise. The daily pressures of work are stressful; much more so having your fitness to practise called into question, assessed, tested and possibly found wanting.

Douglas Bilton
Research and Knowledge Manager

This article is based on ideas that arose at a CHRE seminar held on 28 May 2010, at the Royal Society, London. Discussion centred on a presentation by Professor Ron Paterson, Auckland University.
 

Evaluate before you regulate

When problems emerge in society, there is often a strong temptation to blame a lack of regulation and call for more. This is true of healthcare and in other areas of public life.

We have challenged this reaction with our concept of right-touch regulation, and it was also questioned in a report published last week by the Regulatory Policy Committee. They recommended that we should not assume that regulation is the answer to problems and that other possibilities should be thoroughly investigated first.

Their report is a timely reminder in the light of a recent paper on the issue of regulating healthcare support workers from King’s College London. Here researchers investigated issues associated with the ‘unregulated’ status of healthcare support workers.

This distinct group in the healthcare workforce provides essential and valuable services in the care and treatment of patients and the public in a variety of settings. At present healthcare support workers are not regulated as individuals by a statutory regulatory body, the organisations they work in are usually subject to external regulation, scrutiny and oversight.

The researchers identified four ‘problems’ with this ‘unregulated’ group that they said indicated a strong case for regulation:

• They may have been dismissed for misconduct in a previous role but then employed elsewhere
• They may undertake tasks that they are not trained for
• They may work unsupervised when they should be under the direction of a registered practitioner
• They may be deployed subject to staffing levels and trust policies rather than their training and competence.

And yet, they also stated that ‘it has proved not possible to demonstrate unequivocally that an unregulated healthcare support workforce presents a risk to public safety and that this risk would be prevented by regulation.’ If this is so, how can we reasonably expect that extending statutory regulation to this group would be the most successful way of tackling these four problems?

Before costly decisions are taken to regulate new groups we must look at whether existing systems could be made to work better. We need to know why employers cannot check a job applicant’s past or provide training for their workforce, why registered professionals cannot supervise tasks they have delegated to colleagues, and why service providers cannot be trusted to deploy their workforce in a way that delivers high-quality healthcare.

In short, we need to know why existing approaches are not working. At a time when we need to be extra resourceful and identifying ways of getting better value from existing systems, the Regulatory Policy Committee’s report reminds us that more regulation is not the only way to manage problems.

Kate Webb
Senior Policy Analyst
 

Power to the people in healthcare

An emerging theme in public debate is the idea that people should drive the public services they use. In health, this means people are going to play a more active role in making decisions about their care in the future. For example, the White Paper for the health service in England, Equity and Excellence: Liberating the NHS, emphasised the role of people in health care. In his statement on the NHS White Paper, the Secretary of State for Health Andrew Lansley said, ‘Patients will be at the heart of the new NHS. Our guiding principle will be “no decision about me, without me”. We will bring NHS resources and NHS decision-making as close to the patient as possible.’

It is no longer enough to think of people in the health system as simply ‘patient’ or ‘consumer’ but as ‘citizens’. This view was proposed in a recent report by the 2020 Public Services Trust. Improving Health Outcomes: A Guide for Action, describes citizens in healthcare as people who develop high value relationships with professionals, recognise social responsibilities, and, jointly produce outcomes-based entitlements.

Historically, the relationship between health professionals and people put the former in a position of strength and the latter in a position of submissiveness. However, the sands are shifting. One example of this is the piloting of personal health budgets. This is a policy direction that we have supported. Allowing people to drive choices about their care is part of a patient-led and patient-centred health service. This builds on earlier policy initiatives that supported greater self-management for people with long-term medical conditions.

A patient-led and patient-centred health service requires engaged and well-informed citizens. For CHRE and health professional regulators this means doing all we can to ensure that people have the information to participate fully in their heath care. We have suggested that the registers made available online by regulators should contribute to informing patients in order to maximise their usefulness. Furthermore, we encouraged the health professional regulators to protect the professional titles their registrants use in to ensure that they retain meaning for the public.

More can still be done. Over the next year, we will investigate a range of options for a single portal for information about regulation and a guide to engage effectively with their health professionals. We hope it will also help people make choices and that people will be better equipped to participate fully in their healthcare.

Jason Arruda
Policy Analyst