A doctor writes...

Where have all the nurses gone?
Long time passing
Where have all the nurses gone?
Long time ago
Where have all the nurses gone?
Ersatz doctors, every one
When will they ever learn?
When will they ever learn?

We looked (above) at a harrowing report from a ward nurse on what is really going on in British NHS hospitals. And it goes on because the government has poured millions into senseless guff like the “Essence of Care” rather than into hands-on patient care.

Does anyone know what the salary bill is for “Essence of Care.”?

Since Project 2000, nurses who are not leaving nursing to work outside the NHS, are leaving nursing to become “nurse specialists”. The RCN, lead first by Christine Hancock and then by USA refugee Beverly Malone, sorry Dr Beverly Malone, has worked tirelessly to improve the status of nurses. Improving status means getting nurses away from trivial and demeaning jobs like hands-on patient care. Such work is perceived to be beneath the dignity of nurses. It should be done by others, allowing nurses to get on with the more important task of telling the medical profession how to do their job.

When I addressed Congress last week, I spoke of nursing being at a defining moment. The sort of moment which only occurs every century or so – if you’re lucky.I know there will be some historians here to put me right, but it seems to me we have to look back a hundred years ago to find a similar synchronicity of nursing values with the dominant political ideologies of the day.

"Today core nursing values have been translated into the mainstream of Government policy. This brings with it many opportunities but it has its daunting side too. Nursing is at the frontline.Allow me just to run through some of the ways nursing is being cast at the centre of the current health reforms.

• Nurses are involved in local commissioning for the first time
  
• Nurses are heading up much of the new quality agenda, taking the lead on clinical governance in hospitals and in the community.
• Prescribing powers have been extended to health visitors and district nurses, and are now set to be extended to other specialist nurses.
  

In his speech at Bournemouth, the Secretary of State gave a checklist of ten types of new role or responsibility nurses are taking on and which he’d like to see replicated across the country. They ranged from making and receiving referrals, to performing minor surgery and managing patient caseloads."(Christine Hancock - 2001)

Hancock’s full speech (here) is essential reading.

In it, she describes the deliberate destruction of nursing care in the UK. The government stands by gleefully rubbing its hands. Never mind the quality, look at the bottom line. You can have three of four nurse-specialists for one senior doctor. And let’s allow a few of them to call themselves “consultants”. That will keep them happy.

So how has this affected patient care? What is happening on the wards? Yesterday (above) in “A nurse writes…” we learnt what is was like for the few remaining nuses still doing hands on nursing. And the day before, in Essence of Care we saw what some highly paid nurse-specialists are getting up to. Now we hear from a full time hospital doctor about what is happening on the ground floor, on the wards.

I am an experienced junior hospital doctor, some years into my training to be a respiratory physician. I have recently had a short sabbatical. I’ve certainly had time to stand back, look at the NHS and develop some political sense in the last few months in a way that I wouldn’t have if I had been at work ‘at the coalface’. And I have had time to read NHS BLOG DOCTOR which has amused and interested me, and yet filled me with despair for the mess the NHS has become.

While I can respect the professional knowledge of a few nurse practitioners in a few specialist areas (some of our Macmillan nurses and lung cancer nurses are excellent), they are constantly let down by their lack of general medical knowledge and their inability to treat patients with problems more complex than a single diagnosis.

My approach to the nurse practitioners who do have certain specialist knowledge is to treat them very much like a resource such as a text book or internet article – to absorb their advice (after all, the lung cancer nurses’ knowledge of, say, the neutropenic sepsis protocol is certainly superior to my own) but then to make an informed clinical decision based on my wider medical knowledge and my knowledge of the patient as a whole as well.

Your readers may be interested to know of the sort of sophisticated diagnoses nurse practitioners can come up with when given the opportunity!

I particularly remember a young man we admitted recently with a near-fatal asthma attack. He required intubation and was on a ventilator for six days. He contracted a ventilator associated pneumonia and sepsis. During recovery from this, and whilst on high dose steroids, he had an episode of severe anxiety and paranoia bordering on psychosis. High dose steroids can do this. In other words he had an acute, severe mental illness. We are respiratory physicians. We tried antipsychotic medication but the patient had a severe dystonic reaction. In view of the asthma and the dangers or respiratory depression, we were reluctant to give benzodiazepines.

We needed help from our psychiatric colleagues. Over one long weekend we attempted to contact the psychiatric registrar or consultant on call for advice. You will not be surprised to learn that this is no longer possible: I was put through to a member of the ‘Department of Psychological Medicine Liaison team’.

Their suggestions were:

1. Stop the steroids (The patient had been on maintenance prednisolone at a dose of at least 15mg daily for the past year and was still septic and having acute bronchospasm so we didn’t think much to that idea – can you say ‘Addisonian crisis’,
Mr Liaison Team Member?)


2. And this one I really like, and I quote: “a little dose of propranolol is often helpful in acute anxiety”.

He then went on to explain to me a little more about the pharmacology of increased sympathetic activity in anxiety and exactly how beta blockers would work to make the patient feel better, which was thoughtful of him.

In a sense I suppose both his suggestions were perfectly valid in so far as death, whatever else it might be, is certainly a cure for anxiety.

Many other experiences spring to mind from when I was at work:

• The Patient Group Directive
that allows nurses to prescribe paracetamol to patients to help with the right upper quadrant pain they are experiencing after their paracetamol overdose


• the Macmillan nurse who bullied my house officer into prescribing levomepromazine to a terminal cancer patient who also had severe uncontrolled ischaemic epilepsy, not realising that phenothiazines lower the seizure threshold
  
  
• the night sisters and clinical support workers who will not admit that they cannot cannulate a particular patient until they have ruined all their available veins.
  
  
• Top prize goes to the ‘Infection Control Nurses’ though, for their persistence in trying to make me wear a badge with a smiley face and the words ‘It’s okay to ask me if I’ve washed my hands!’
in a cheery font. I asked them whether I should wear multiple badges encouraging patients to question me on every area of clinical safety:

‘Don’t let me forget not to flush your venflon with neat potassium'

or

'Remind me not to defibrillate you when you are in sinus rhythm’

Like all nurse-specialists, ‘Infection Control’ nurses do not cerebrate outside their protocol driven defined area. The best method of infection control must be the ‘not letting patients with horrendous bedsores sit in their own shit for hours on end’ method?

Can’t seem to interest them in that.

My wife is a graduate entry medical student on one of the new Problem Based Learning courses (otherwise known as F.O.F.O. – fuck off and find out) and a lot of her preclinical teaching sessions were led by Nurse Practitioners among other ‘healthcare professionals’ such as social workers, psychiatric nurses, occupational therapists and so on.

She is already developing a healthy disregard for such people having spent an amusing afternoon being taught pelvic exams by a practice nurse who persistently referred to the 'labia Mallorca and Menorca', and having to explain to a midwife that her patient’s baby was not born with a port wine stain because the mother had got severely sunburnt in the same area as a child.

We can both see the point of encouraging a problem-based and self-directed approach in learning (and indeed I have noticed when teaching medical students on the wards that the graduate entry students are a lot better at clinical problem solving and so on) but it would be nice to think that the tutor supervising the tutorials was at least capable of correcting any gross misapprehensions that the students come out with. Sadly it’s not the case.

People need to know what is really going on.

++++++++++

The world is upside down.

The nurses are leaving nursing to do jobs for which they do not have the training. Junior doctors are being deskilled. They are being deprived of their apprenticeship. (Classic case here - the SHOs in this hospital will never learn) So many of the jobs they traditionally did are being taken over by the “nurse-specialists” or even the ubiquitous HCAs. Yes, it is easier in a way to allow a “nurse-specialist” to perform one protocol defined function over and over again than it is to train a new junior doctor to do it ever six months.

But how will that doctor ever learn?

The government is allowing this to happen. Deskilling the NHS reduces expenditure so the government is in favour. There is even has a slogan. (Well, its New Labour, so of course there is a slogan!). This is not deskilling it is:

"Raising standards through sharing excellence"

Hmmm, yes. That sounds good, doesn't it. Say it over a few times. Hum it. "Sharing excellence". Yes, I do like that. And there is even a government funded club for "sharing excellence". It is called The BenchMarking Club. Have a look at it. It uses words like "plenary" and "matrix". Have a look at the meeting of the Summer Plenary on 21 June 2006 in York.

The focus of the plenary was on new commissioning arrangements and gave us the opportunity to reflect in particular on practice based commissioning and the strategic commissioning role that the new Primary Care Trusts will be taking on. We had a number of stimulating and interesting presentations. It was an excellent plenary with many experiences and learning points being shared. My thanks to colleagues who presented and all who participated in the plenary. (full speech here)

Dr Crippen loses the will to live as he wades his way through documents like this. They are truly beyond satire. But you should read them. This is yet another example of where the New Labour millions have gone. All over the country "plenaries" have been meeting in Five Star hotels, on your behalf and at your expense. In the meantime, patients on the wards are dying of bed sores and starvation.

This is New Labour at its best. Behind all this jargon from the Ministry of Truth, the NHS is being dismantled. Just as New and Old Labour dismantled the secondary education system.

Soon the NHS will be like the comprehensive schools. Wonderful for “the people” but do not expect Tony Blair to send his children to one. And do not expect the “great and the good” to use the NHS.

They will go privately, thank you, and see a doctor.

And how can Dr Crippen best sum this up? By repeating the words of this experienced doctor about nurse-specialists running "infection control".

The best method of infection control must be the ‘not letting patients with horrendous bedsores sit in their own shit for hours on end’ method.

Can’t seem to interest them in that.