The Sunday Times

December 2nd, 2012

There is an unspoken fear driving our nurses to cruelty

Yesterday was the 70th anniversary of the publication of the Beveridge report, which gave Britain its nobly conceived welfare system, including our cherished National Health Service. But only two days earlier, in the midst of the Beveridge celebrations, the secretary of state for health felt obliged to speak out against a culture of cruelty in the NHS and in social care as well. Jeremy Hunt’s chilling phrase was “the normalisation of cruelty” — perhaps, he said, the biggest problem of all facing the NHS — “where the unacceptable is legitimised and the callous becomes mundane”.

How good it is that he spoke out so unequivocally. But how late. It’s a mystery to me why it has taken so very long for any government to admit the truth. None of the horrors the minister talks about is new.

It must be more than 20 years ago now that I started writing about the dreadful things that were going on in some hospitals. At first my accounts were tentative, based on some shocking observations of my own in several of the great London teaching hospitals. But soon my postbag became so swollen with anguished readers’ stories about hellish experiences on NHS wards that I began to realise something widespread was going on. A culture of cruelty had developed.

At the time it was quite impossible to say so. And when, long ago, a sub-editor (on another newspaper) gave an article of mine the headline “The devil nurses of the NHS“, I felt uneasy: there were and are plenty of fine nurses who would rightly be offended.

But how else would you describe nurses who deliberately and perversely denied painkillers in an intensive care ward to a man who had just had both legs amputated? I saw that for myself in about 1995 in a top London NHS intensive care unit, where my mother was recovering from an operation.

My mother was doing well but she insisted I try to help a man at the other end of the ward who had been screaming in agony throughout the previous night because the nurses had let his epidural drip of painkillers run right down until it was too late to find an anaesthetist to refill it. Now his drip was low again and he was terrified.

So I went to the nursing station and tried politely to explain his fears, whereupon several young nurses very rudely told me to get lost. And sure enough, they let the drip run out and the patient spent the following night screaming in agony again.

A couple of rogue nurses, you might say.

But there was and is too much evidence the other way. I know that public satisfaction with the NHS is generally high and I know there are excellent nurses with an excellent culture of care and compassion.

One example is a post-operative ward in Gloucestershire Royal Hospital, where I spent several hours a day a couple of years ago for most of three weeks, supporting a patient with a learning disability. The nurses could not have been kinder or more cheerful. If they were overworked they didn’t let the patients see it. I don’t suppose they were better paid or less busy than other nurses, but something about the culture there inspired them to be the kind of nurse that everyone hopes for. It can be done.

All too often, however, it isn’t, as people are beginning to realise. It’s hardly necessary to repeat all the horror stories that Hunt listed. A mention of the cancer patient at St George’s in Tooting, south London, whose desperate thirst drove him to call the police, or the needless deaths at Stafford Hospital are enough to make the point.

The question is why this culture has developed and why it is so prevalent. It clearly has little, if anything, to do with pay or workloads: the many compassionate nurses in the NHS prove that. Nor do I think a culture of active cruelty has anything much to do with the training of nurses.

I suspect this institutional cruelty is directed mainly at certain kinds of patient. One day I visited a friend who had just given birth in a famous and respected teaching hospital; the treatment on her ward was excellent. But the same evening I talked to a man who had just visited his mother in the geriatric wing of the same hospital and her treatment was horrifying. He had to go in every day to help her eat, to wash her and to demand some attention from the unpleasant nurses; otherwise, he said, she would be lying in vile neglect like the other patients. There were two entirely different cultures in the same prestigious hospital.

It seems to me the worst NHS and social care horror stories usually have to do with the very old or with people who have mental disabilities or mental illnesses. The scandal at Winterbourne View, the private care home that was shut down after the discovery of horrific treatment of the patients, is a case in point: abuse of this kind is becoming more prevalent in society generally, according to government statistics issued last week.

Perhaps that isn’t entirely surprising. We all have complex and fearful attitudes to ageing and to mental infirmities.

Old people, especially the very frail, are a frightening memento mori. One day I, too, they remind me, will lose my teeth and hair and hearing. One day I will probably be querulous or immobile or doubly incontinent. One day I may lose my mind.

Nobody likes to be reminded of all that and most of us try to forget it for most of the time, but nurses can’t. As well as that, they face the constant difficulty of caring for people who are not going to get better and who may not even appreciate what they do.

I suspect something of the same goes for patients with mental problems: they frighten people in a deep but unspoken way. And the way we deal with people who are frightening is usually to dehumanise them.

We can dissociate ourselves from them by pretending they are different from us, that they are other. And, as history has persistently shown, in the dehumanisation of soldiers in combat, as well as in ethnic cleansing, people we have dehumanised are very much easier to abuse; in fact, abuse becomes a way of asserting our much desired difference from them. That’s why people used to jeer at the local madwoman or the village idiot: it’s a form of self-protection.

None of this excuses callousness or inhumanity in the NHS, in social care or anywhere else. To try to understand is not to excuse. But explanations are urgently needed. Without them the culture of cruelty — the “normalisation of cruelty” — will grow. Beveridge would have been astounded.

The high price of our dementia care failures, Letters, page 25. Is this the future of the NHS?, Dominic Lawson, Magazine, pages 68-73