We are delighted to welcome this message from Elaine Maxwell, addressing the current challenges facing nurses and nursing in the UK National Health Service (NHS). Her message has world-wide implications!
I am one of those nurses, I think the NHS is a wonderful jewel built on a shared sense of equality and justice (and I have worked briefly in private healthcare both in the UK and in the USA). The challenge for the NHS is that there are different opinions on what it is there for and how to evaluate it. Discussions are more often focused on
Elaine Maxwell
ideology (socialism versus market economies) that what the staff within in actually do.
The Commonwealth Fund (2014)1 rated the NHS as first internationally for effectiveness, safety, patient centeredness, cost and efficiency and third for timeliness of care. In spite of this, successive UK governments of both main political parties have focused on cost savings and faster access.
Starting in 1997 with the New Labour Blair Government, the definition of a good service moved from a broad base to focus on access and cost. Targets were introduced for waiting times for both emergency and elective care and organisations incurred financial penalties for failure to achieve them whilst at the same time they had to cut unit costs in order to become quasi autonomous ‘Foundation Trusts’. Something had to give and in the NHS it was nursing.
Nurses failed to articulate their therapeutic contribution and some enthusiastically embraced the role of managing patient flow to achieve access targets. This was a tangible, visible contribution to the new managerialism agenda as opposed to more opaque, but critical, nursing interventions. This lack of visibility led management consultancies to recommend wholesale cutting of nursing posts, for example McKinsey advised that nursing posts could be cut in London to save £421 million a year without any impact on the quality of the service2.
This perfect storm was exemplified by the failings at Mid Staffordshire NHS Foundation Trust and described in detail by the public inquiry3 which clearly laid the blame for many of the failings at the feet of nurses. Although the report detailed the swingeing cuts in nurse numbers prior to the failures, it also suggested (without any empirical evidence) that academic nurses with the ‘wrong’ values had been recruited and that potential nurses should work as unregistered care assistants before being allowed to study. Despite concerns from nurses4, this idea is being piloted in the NHS and a recent BBC programme demonstrated that nurses and students have bought into this rhetoric5
Following the publication of the report, the Government commissioned a review of Trusts with apparently high mortality rates6. These ‘Keogh’ Trusts were found universally to have ‘insufficient’ nurses and those that recruited significant numbers of nurses have improved their quality outcomes the most.
So UK nursing is currently confused. There is a belief that increasing the number of registered nurses improves quality as demonstrated by Aitken and colleagues7 but this type of cross sectional correlation study does not explain what it is that nurses actually do to create this quality. The Chief Nursing Officer for England has focused on individual nurses’ values with her strategy ‘Compassion in Practice’8. The Quality Improvers, with a nod to LEAN thinking, are focused on the getting patients through the system faster with nurses managing the flow so that medical staff can provide their clinical intervention. No one, it seems, feels that nurses have a unique therapeutic contribution and nurses who trained at a time when Henderson’s definition of nursing was embraced and who learnt and practised nursing models are now in the twilight of their careers.
With increasing numbers of people with multiple co morbidities, the traditional episodic medical treatment model looks increasingly unlikely to meet the needs of our population but without nurses who actually nurse, more and more people are readmitted to our hospitals and so the vicious cycle of speeding up the flow intensifies.
When Margaret Thatcher sought to reorganised the NHS in 1983, her advisor said “In short, if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”9. I contend that if Florence Nightingale were carrying her lamp through the corridors of the NHS today she’d be asking “Where are the nurses?”
So what can nurses do about it? We need to reclaim our area of practice and make it visible by articulating our unique contribution, which is often tacitly shared amongst nurses and patients but policy makers and managers can be entirely oblivious to it.
We need to use the language of those with power and describe how nursing is more than a support service to medicine. Nursing has its own independent added value that can realise benefits for organisations as well as patients. The Dutch community nursing service, Buurtzorg10 has done this by ensuring that care is led by highly educated RNs who work autonomously with few protocols. This model has been independently audited and shown 40% reduction in cost of service with improved quality scores as nurses have been empowered to direct their work to where they add the most value; nursing not management. When we speak this language, we connect with others and the value of nursing can be understood and celebrated
1 Commonwealth Fund (2014) Mirror, Mirror on the Wall: How the US Health Care System compares internationally www.commonwealthfund.org
2 Nursing Times news report (2012) http://www.nursingtimes.net/nursing-practice/clinical-zones/management/london-hospitals-told-they-could-slash-nursing-bill-by-421m/5041068.article
3 Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry London: The Stationery office http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report
4 Maxwell, E. (2013) Francis inquiry: compulsory work as healthcare assistants won’t make better nurses British Medical Journal, 346
5 Grumbling Appendix blog “Do Not adjust your (mind) set “ 25th July 2015 https://grumblingappendix.wordpress.com/
6 Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report London: NHS England http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx
7 Aiken, L. H. et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study The Lancet 383(9931), 1824-1830
8 Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser (2012) Compassion in Practice: Nursing, Midwifery and Care Staff Our Vision and Strategy. London: Department of Health NHS Commissioning Board. http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf
9 Griffiths R (Chair) (1983) NHS Management Inquiry London: HMSO www.sochealth.co.uk/history/griffiths.htm
NurseManifest 
Our colleague Elaine Maxwell is spot on in her assessment. The model here in Ohio set by a national for profit chain which buys struggling community hospitals is to cut nursing staff positions and make up the difference with mandatory overtime for nurses already working 12 hour shifts. Ohio has a “safe staffing law” which is disregarded at will without consequence by those whose agendas are profit and careerism to the exclusion of basic safety It’s time to tell the public.
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Thanks Doris, it’s interesting to hear that the problems are the same across different countries and this strengthens the need for a single. global nursing voice
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Sadly there is a far simpler explanation of why the Trusts are failing in large measure and why some Trusts succeed. It has little to nothing to do with nursing theories and nursing activities and all to do with what Florence Nightingale would actually be asking, which is: Where are the financial risks being managed and is the risk management efficient.
Because Florence Nightingale was a first rate statistician and guided as much by economics as caring, she would look at the Trusts as both insurers and care providers. Under the old NHS the financial risks were managed centrally. If a geographic area experienced higher than average costs under the centralized risk management, there were usually other geographic areas that had lower than average costs. The net effect was that assets were fluidly transferred to where they were needed and the average costs tended to stay within a very narrow range, making it easy to fund the NHS.
Under the newer, decentralized risk management and service delivery model, the Trusts are managing the financial risks for a far smaller cohort of citizens. Each Trust has to allocate its meager resources to meet the needs of its constituents. In the sublime twisting of logic, mathematics, statistics and economics, these local allocation decision-making processes are sold to the gullible as providing more local control and consumer choice when the harsh reality is that the consumers are gravely hurt and the choices that are being made are choices that many smaller Trusts cannot make at all because they cannot adequately fund the most basic services that are needed.
A simple example. Let’s do the old Guns & Butter trade off but we will look at it as Pediatrics vs Geriatrics. In the old NHS you could fund, at a national level, both adequate geriatric services and adequate pediatric services because in a big pinch if there were inadequate pediatric providers (Nurse, doctors, dentists…) in a geographic area you might send patients to a facility across the country, or you might send some doctors, nurses etc to the area with the temporary increased need. The system equibrilated over fairly long periods of time and if the demographics of a local area changed, the sorts of providers that would be assigned to that area would change.
But in the smaller geographic areas of Trusts, this is far harder. Those consumer-based allocation decisions look instead like a forced choice between concentrating on pediatric services or geriatric services when both cannot possibly be adequately funded and the option of sending overflow patients to other locales becomes far more difficult. So you wind up with allocative decisions that were unnecessary in the old NHS, but must be made in the new Trusts.
So Trust A has enough resources to hire 9 nurses. Based on the local demographics, it needs 4.5 pediatric nurses and 4.5 geriatric nurses. But it cannot hire half nurses. The local decision makers are forced to make a decision between Case 1: “4 pediatric nurses and 5 geriatric nurses” and Case 2: “5 pediatric nurses and 4 geriatric nurses”. When such decisions are actually made the results should be clear. When Case 1 is chosen, there is a surplus of geriatric nurses. Reformers will note this in their next year’s report as a grossly inefficient use of resources and the geriatric providers will be directed to become more efficient. The same reformers will also note that the pediatric nurses are not meeting the needs of their patients: Longer waits for diagnosis and treatment, higher levels of patient complaints about service quality and the staff will be stressed out.
When Case 2 is chosen, the reports will be reversed. There is simply no way for the nurses to satisfy the reformers because the mathematics is wrong, not the nurses. Now note that if we had 10 such Trusts and we simply strove to meet the needs of all the populations with a single Trust, that Trust could completely meet the needs of all its patients with 90 nurses, 45 pediatric nurses and 45 geriatric nurses. The problem disappears when there are sufficiently large populations to allow for more efficient allocative decision making.
Now this hasn’t addressed the inefficient financial risk management at all, so far it is just the most basic math and statistics. Just as is true in our domestic health insurance market, the carving up of small portfolios of risk in the various Trusts, leads to greater variability in the average costs of providing patient care for the Trusts, compared to the situation in the old NHS when the risk management was centralized. Each trusts is far more likely to have a very high average cost (or a very low average cost) than the NHS would ever see.
When a local Trust encounters a sicker than average population it increases the demand for services. The local Trust exhausts its resources faster than intended. This, of course, leads to longer waiting times, missed and delayed diagnosis and treatment, consumer complaints and muck-raking reports about the presumed failures of the nurses to meet the needs of the patients. Each Trust fails alone.
But on the other side, there are the Trusts that have had unusually healthy populations. They have far less demand for care than anticipated and will have short waiting times, timelier diagnosis and treatment, high consumer satisfaction scores and they will be used by reformers to show that localized Trusts can indeed function with lower levels of resources. Reformers will either use such “Exemplars” as proof of the success of their reforms, or they will impose cuts on these high performing Trusts, with the healthier populations, because they obviously do not need the level of resources they enjoyed.
The key here is that there is nothing the low performing Trust (or the High performing Trust) did to make their population healthy or unhealthy, it was a statistical anomaly and in all likelihood, if the resources remain the same, the two Trusts will switch roles the next year.
This is what Florence Nightingale would actually notice about the reform of the NHS and she would set to working out the mathematics, statistics and economics of it and browbeat the reformers until they acknowledged that their improvements have all the substance of a Ponzi scheme. Until more nurses follow Florence Nightingale’s real footsteps and acquire the skills necessary to appraise the increased financial risks in small portfolios/Trusts, nursing is doomed to keep shooting itself in the foot, missing the big picture, and getting caught up in superficial details that will not fundamentally address the consequences of capitation-financed health care, large numbers of inefficient insurers/Trusts and the entire “managed care” paradigm that cannot help but fail.
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For historical perspective, I wrote similar thoughts in a book review of “Betraying the NHS: Health Abandoned” by Michael Mandelstam in the Journal of Psychiatric and Mental Health Nursing. The review was published in 2007, years before the NHS White Paper and the destructive “reforms” that followed.
Cox, T. (2007). Book Review: Betraying the NHS: Health abandoned by Michael Mandelstam. Journal of Psychiatric Mental Health Nursing, 14(7): 715-716.
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Elaine and Thomas, your observations mesh and complement each others perspectives on root causes of current systems distress at the NHS. Thomas, I found the information you shared very helpful and, again, the financial dimension of care in the US also depends on pooled risk and shared resources. It’s not working here and hasn’t for a long time. Thank you.
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Doris,
Thank you. Check your email at Capital – I sent you a copy of “Standard Errors: Our Failing Health (Care Finance) Systems and How to Fix Them”.
Even many people as well versed in the consequences of inefficient risk management are surprised at the severity of the consequences of these flawed health care finance mechanisms when you actually work out the details and what appalling disasters Paul Ryan’s budget proposals would be if they were ever to be enacted.
tc
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