The Sunday Times

October 16th, 2011

Take three bombs … my prescription to cure nursing

What should happen to a nurse who neglects her patients and stays chatting idly at the nursing station while they cry out helplessly for bedpans, or scream unnoticed when their anaesthetic drips have run out? What should happen to a nurse who is prepared to leave patients unfed and unwashed, lying in their own excrement, who scolds and insults them and has so little care for their basic needs that doctors have to prescribe water to make sure the poor souls get enough to drink to survive? This ought to be a rhetorical question. The obvious answer is that such a nurse is not worthy of the name. She (or he) should be struck off the official register of nurses permanently. So should any more senior nurse who tolerates such cruelty or fails to notice it. However, that is not what happens.

Last week, in yet another shameful NHS nursing scandal, the Care Quality Commission (CQC), prompted by the health secretary, reported the findings of unannounced inspections of 100 hospitals. What it showed was how widespread this nightmare nursing is across our hospitals.

The report showed that nearly one in five of the hospitals was breaking the law with its failure to treat the elderly with even the minimum care and respect. Just over half were falling short of proper care standards and one in three was struggling to meet even basic legal standards. It found that nurses’ bad practice could not be explained away by understaffing; the report attributed it to a culture of neglect.

Nor is this shamefully poor nursing restricted to geriatric wards. There is plenty of evidence that it can also be found on other wards — though so, too, can good and excellent nursing. If bad nursing really is so widespread, what would you expect to happen to all the bad nurses? The answer ought to be mass sackings. In a rational and moral world you’d expect shock, horror and breast-beating from the regulatory bodies and nursing establishment, and for lots of nurses to be swiftly struck off the professional register of the Nursing and Midwifery Council (NMC). You’d be wrong. In 2010-11, of the nearly 670,000 registered nurses, only 198 were struck off. Why so few? Nurses, like teachers, seem beyond punishment.

Ministers and health professionals were wringing their hands all week, with the usual evasive wittering about the importance of learning lessons and old people’s right to dignity. The word “training” was used a lot: Joan Bakewell even suggested “empathy training”. Andrew Lansley, the health secretary, came up with the idea of encouraging whistleblowers, but that is a curious approach to professional regulation. Otherwise there doesn’t seem to be much of a plan or even much of a response. Yet there are some very obvious things to do.

The first is to put a bomb under the NMC. If anything is wrong with nursing, as the regulator for nursing and midwifery, it has a duty to fix it. This council exists to safeguard the health and wellbeing of the public, set education, training and conduct standards, and investigate complaints. It says proudly that only 0.6% of registered nurses and midwives are referred for investigation each year. Is the NMC unaware that something terrible is going on and that it has a responsibility to fix it and that this figure doesn’t make any professional sense? Above the NMC is the Council for Healthcare Regulatory Excellence. Excellence! Accountable to parliament, this independent body oversees the work of the regulators of all healthcare professionals, including the NMC. It seems surprisingly satisfied with the NMC: it did an audit early last year and offered no serious criticisms. Surely there should be a bomb under this body too. It cannot be right that both these regulators should have presided without any noticeable expressions of guilt or shame over such a national disgrace.

No doubt the trustees and senior executives are worthy people — their biographies suggest they are. But they all seem to be part of that quangocratic medical establishment for which the kindest word is “complacent”. I suspect they are too much part of the public sector mentality and are thus unable to oversee with independent eyes.

In 2009 one of the very few nurses the NMC did strike off for misconduct was a whistleblower who secretly filmed neglected patients for Panorama to expose bad nursing practice, having despaired of being heard in any other way.

Another bomb needs to be targeted at nursing training — currently overseen by the NMC. At long last it has been acknowledged that current training isn’t fit for purpose, even by the nurses’ union, the Royal College of Nursing. Nursing degree courses should be revised by independent academics, dumping extraneous issues such as promoting equality. Bring the nurses back onto the wards for more than 20 weeks a year to learn by expert example. Bring back student nurses’ pay. There should be many levels of training, covering all practical and intellectual aspects and tailored to nurses with different strengths. All are important.

Empathy training is unnecessary: by 2013 all nurses will have to complete degrees and undergraduate nurses are already inundated with coursework on ethics, dignity and cultural understanding — it can’t be said to be working very well. What are needed are not empathy workshops but discipline, hierarchy and education by example — currently rather feebly called leadership.

With the nursing reforms of the 1980s and their pursuit of equality, university status and individualism for nurses, and in the contemporary hatred of deference and authority on the wards, the shared purpose of medical care was lost.

Bring back hierarchy and the chain of command. Bring back the old state enrolled nurses, who were carefully trained for bedside nursing but were less qualified than state registered nurses or graduate nurses. Train the auxiliary healthcare workers, register them and let them become an important part of the nursing team, not just the unskilled hired help.

Bring back the honour and meaning of the word nurse, applying it to every member of the nursing team, whether superskilled or modestly trained, whether a cardiac intensive-care specialist or a kind person skilled in giving bed baths. Bring back the old chain of command, in which everyone was responsible to those above them and for those beneath them. But what’s needed is a lot of creative destruction first.