Saturday, 10 October 2009

Thoughts on Spending 31 Hours in a NHS A&E with a 87 year old

What, I wonder, would the various denizens of the blogosphere have been saying if they were sitting there with me and my ailing Mum?

The rabid right-wingers would have blamed the incentive-free state bureaucracy I suppose. But they would be wrong there; I really don’t think it had anything to do with the governance arrangements or lack of a direct profit motive. The people, from the consultants down to the porters and cleaners , did seem genuinely open, friendly and willing to help.

Most of my comrades on the left might have muttered about still catching up with years of underfunding, and there were certainly evident staff shortages , though mainly, as far as I could see, unpredictable ones as at least two nurses went off sick in that 31 hours. It’s hard for any organisation to deal with that.

My blogroll’s resident HR expert might have had something to say about the composition of the staff team though; to be frank I thought there were too many doctors and not enough nurses. This may seem an unusual complaint. It only makes sense when one realises that the doctors appear to operate in separate little kingdoms of medical specialism. About a third of our wait was simply down to the A&E team referring some x-rays to the orthopaedic surgeons for a second opinion on whether there had been a fracture. And whilst we waited for that second opinion nothing else happened, no temporary admission could be made because the separate specialist kingdoms hadn’t decided whose kingdom (i.e. what kind of ward) Mum was going to be admitted into. I believe this is called silo working in management speak. Meanwhile the nurses on A&E were doing their A&E thing which, when it comes down to it, is basically triage. So if someone is marked as awaiting a second opinion they just move onto the next case unless there is some urgent call from the bed which has been parked in this triage operation. No thought beyond basic feeding and toileting is given to the cases not identified as urgent. If there had been more nurses the various doctors’ instructions might have taken effect rather quicker – and more holistic care might have actually been provided. Also, I’m not certain why it would have been such a great disaster to get Mum somewhere comfortable, even if it did prove to be the wrong ward and meant her having to be moved the next day.

My blogroll’s representative Spiked-influenced commentator and general enemy of the risk adverse culture would also have passed a few harrumphs about the reason for the final section of our wait – the seeming impossibility of assembling two spare members of staff to push the bloody bed containing my Mum to the ward. First we got a single porter; then we got a cleaner but no porter, and finally, 4 hours after the consultant had instructed an early transfer to a ward, we got both. Of course I pleaded and pleaded to be allowed to help to push the bed myself – but, no it was ‘against the rules’, 'not procedure' there were Health and Safety concerns and so on. So Mum sat waiting, immobile and in semi-public view, in A&E till two people could be assembled, one to push the bed and one to simply open the doors and push the lift button.

But most of all I reckon Boffy will be slowly and sympathetically nodding his head and biting back the urge to say, "I told you so - the left has got to be about more than just knee jerk defence of the NHS" . & so he did. Several times.


  1. Charlie, I'm no HR or management expert, but I'll try to make a contribution here, from observation of failing public services. And let's face it, four hours to assemble two porters in one place to do a ten minute job is a failure, nothing else.

    My sphere is not health but public transport and the problems are the same. Not enough of the extra money has made it through to reliably-delivered success on the front line.

    My observation is that it's not just about the lack of numbers of frontline nurses or porters, but the lack of a functioning command structure within the front line staff. In an army analogy I'm not really personally qualified to use, there are plenty of generals, staff officers and there *might* be enough private soldiers, but not enough field captains and NCOs to make sure orders are implemented and to adapt to events as as they happen and make do (eg nurses going off sick in mid-shift).

    We see all parties saying they will make cuts but spare the front line by attacking back office, PC bullshit & bureaucracy. But the problem is that the front line isn't currently functioning well enough and "getting the bureaucrats off their back" won't alone do the trick to help. I'd like to see some of the keen young staff officers at HQ given a pistol and, under the tutelage of a grizzled old sergeant, sent off to help make the front line deliver better.

  2. And another thing. The other solution Labour and Tory will proffer in the context of cuts will be more privatisation.

    But then we get a situation where the delivery of the public service is no longer the objective, whilst gaming (and defrauding) the system to make as much money as quickly as possible is. If Boffy thinks gaming the targets regime by public sector bureaucrats is bad under public sector control, he should see how bad it gets under privatisation. Totally demoralising and disastrous for front line staff, and for the public service consumer.

  3. Thanks Strategist,
    I certainly think you're onto something with your NCO analogy. Most industries have been through a process of management delayering which is dressed up as 'devolution of decision making'. In reality IT advances have meant that targets can be set and performance monitored by top management in a much more direct way than 40 years ago, without the need for intervening layers of supervision. The paradoxical result is actually a decrease in local workplace autonomy for many and loss of job control. I don't think mainstream political debate captures very much of this, which is an increasingly central part of many people's work experience. Try this cartoon as a example of what I'm on about.

    Boffy certainly isn't a right-winger, indeed he is considerably to my Left. But he thinks heretical thoughts so I find him stimulating to read.

  4. The last point about waiting for two porters to move the bed absolutley rings true with me. Four years ago I was on a trolley in A&E waiting to be transferred to a ward. I had a dislocated kneecap and ruptured patella tendon - that is, the big tendon you can feel just below your knee on the front of your leg was torn completely through and my kneecap was around 3-4 inches north of its normal position. This needed a surgical repair that I would eventually have to wait 4 days for.

    Anyway, A&E was pretty busy and they were having trouble finding some porters to move me. My mum and dad had both come up to the hospital and we had exactly the same "why can't we help to move him" - "it's against health & safety" nonsense.

    Some time later (there obviously still being a porter-shortage) a single porter turned up with a wheelchair to move me to the ward - because one porter with wheelchair is safe, whereas one porter + one civilian with bed is unsafe. This makes clear that this sort of 'health & safety' observance is all about technical compliance rather than actual safety - better to be unsafe within the rules than actually safe but rule-breaking. Bearing in mind the state my leg was in, trying to move me from a bed to a wheelchair (with only one porter!) would obviously have been far more risky for my health and safety than any of the alternatives. Not irrelavantly from my point of view, it would also have been agony - as you can imagine, it was a touch sore and very sensitive to movement.

    We then had a bit of a standoff with me refusing to be moved into a wheelchair and the porter insisting that there was no other way of moving me. Eventually he stomped off, clearly giving the impression he thought I was being unreasonable and difficult. I was eventually moved several hour later at about 3 in the morning, which meant that everyone else in both the A&E triage area and the ward to which I was transferred was woken up while they were at it.

    That whole incident was so daft it makes me cross just writing about it.

  5. Hello Charlie, sorry to hear about your mum. I have just had six months of the same kind of thing with my own aged parent.
    One major problem with thinking about the NHS
    is that it is just so huge it is impossible to generalise. I have had some excellent experiences over the past ten years and also some very frustrating ones. For what its worth, one consistent experience is that many nurses no longer seem to see nursing, as in looking after patients, making sure they are comfortable, well fed and clean, as their top priority.


    Rob Killick

  6. I spent 4 hours waiting in Moofields Eye Hospital A&E last Friday.

    It wasn't fun, but the staff were incredibly helpful and courteous. It was hardly their fault that 2 doctors were off sick that day.

    Though, yes, the triage system could have been better, whilst I sat there waiting, bored out of my mind, I couldn't help thinking how damn lucky I was that at the end of my 4 hours, i'd be seen by a professional and given medical attention, for free. I thus spent 4 hours waiting, but without having to wonder if I could afford both the appointment at the end of the 4 hours, but any subsequent treatment.

    And that's a real blessing, whatever else is wrong with the NHS.

  7. Paul,
    Yes, the NHS is a Good Thing compared to, say, the North American system. It is also genuinely popular, which is why no sane politician of any party will ever come out against it at the level of principle - unless, like Daniel Hannan, they're trying to cultivate a niche market("Free Market, Neo-Hayekian, Libertarian Headbangers For Change!"). No, they don't do it at the level of principle - they do it 'invisibly' at the level of funding and governance arrangements - and of management by targets.

    Rob is quite right to say the NHS is so vast that generalisations are difficult to sustain. So I didn't try to generalise in my post, but simply record a particular experience and personal musings on how others' might have reacted to it. However, I do think that his tentative observation about nursing - it's no longer primarily about ensuring patient comfort - is interesting, and compatible both with some of the things Strategist said higher up this comments thread and my observations about their being the wrong kind of staff mix in the A&E my Mum suffered.

    Boffy's blog is strong meat - he's an unorthodox Trotskyist economist who makes many posts in impeccable (or impenetrable?) Marxist language. Some find this a bit off putting. But there is a rigour and a logic in his thinking - and a lack of conservatism. That's the problem with the Left just taking the line that 'The NHS is a Good Thing' - it's a conservative position that addresses neither the changing nature of potential health care or the deep variety of people's real experience with the NHS. It may get Labour some votes in the short term but it's not enough - and it won't withstand more and more people experiencing what I and my Mum experienced.

  8. Charlie,

    Thanks for the comments you have made here. Actually reading your account, my first reaction far from being one of "told you so", was deepest empathy, because over the last ten years at least I have had many similar experiences.

    Its necessary to start by saying that we do not blame the workers involved. I wouldn't have blamed a BL worker for building a shit Allegro. Part of the problem is the size of the NHS, but that is only part of the problem. Part of the problem is the lack of clear lines of management control. But, these are symptoms not causes.

    I can give another example not related to the NHS. I go to my local Council Sports Centre Gym regularly. Most of the custoemrs complain about the service provided. Many of the things don't require huge sums of money, a bit of cleaning here, a bit of paint there. In the gym one problem only requires two pieces of equipment to be moved - a bit like your problem with the porters - but no one will take the decision to move them, because it is the responsibility of someone higher up! A common feature in the Public Sector I found was a lack of initiative, because no one will take a decision that they think they might get blamed for at some point in the future.

    Your correspondent who talked about ythe consequence of privatisation is partly correct, though I have to say that my experience of using a private clinic (though on the NHS I hasten to add) was incomparably better than the experiecne of the NHS. And, of course the motivation of private Capital is profit not public service, but as Lenin pointed out even Capitalists recognise that to make profits you have to actually meet consumers needs! A motivation that is lacking in the mindset of State bureaucrats. But, the real solution lies not with a return to private Capitalism from State Capitalism, but with the transfer of ownership into the hands of workers themselves. That will remove the bureaucracy and free up the initiative of the workers themselves.

    I've just dealt with some of these issues Here

  9. On a similar vein, the current Post Office dispute raises similar issues. Of course, we have to support the posties, and the reaction of the gutter press in talking about the dispute amounting to committing suicide are sickening. But, they do have a point! Were the PO a private enterprise the dispute would hit the profits of the company, and pressurise it into concessions. It isn't. Its a state capitalist enterprise that Capital seeks to dismantle because technology has moved on, and alternatives exist that are more efficient from the perspective of Capital as a whole. So the private Capitalist competitors will rejoice!

    The real alternative for posties is actually to be able to take the Post Offie into their own ownership and control. That way it could be linked up as beofre with telecommunications providing some protection as eelctronic mail continues to replace snail mail. That way, Post Offices COULD become a Post Office Bank, offering a range of services and providing a link between the Co-op Bank, and Credit Unions, so as to provide Bank and financial coverage for all sections of the working class.

    As Marx put it the working class and its Trade Unions and other organisations remain to focussed on the downsidres of Capitalism, and on fighting these guerrilla battles, rather than looking to the opportunities which Capitalist development provides them by harnessing the means of production udner its workers ownership and control.

  10. I spent a very long time looking after my mother, who had multiple ailments (she eventually passed away with cancer). The fact that my Sister is a lecturer in Nursing at Birmingham University meant she knew how to deal with such difficulties. Which is not open to all...

    I deeply sympathise with you on this.

  11. When did "You must have two porters to move a bed" creep into the NHS? 50 years ago when I was an NHS porter, we moved patients on beds on our own when necessary; and those beds were a damn sight less manoeverable than modern beds. I would say that "You must have two porters" smacks of an old Spanish custom of make-work, except that in Spanish hospitals it takes only one porter.

    Not allowing patients' accompaniers to move patients in beds or wheelchairs does make some sort of health and safety sense; though I find it even more exasperating than most do.

    When I worked in the NHS, I wondered about running hospitals as Co-ops. However, I could not find a way of squaring workers' cooperative management with doctors taking full clinical responsibility for their patients. Maybe somebody else can.

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