Category Archives: NHS

Ambulance, Community Nursing, Health, NHS, Responding to media

Ambulance or Nurse?

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The Independant have an interesting story where, due to the shortage of ambulances the plan is to send community nurses first for patients over the age of 65 who have had a fall.

This is a bad idea.

But first, as a quick update on my career, I went from nursing into the ambulance service, and then returned to nursing. At the moment community nursing. So I’ve done both of the roles that the article is talking about.

The ambulance role is very much different from community nursing. When a community nurse sees a patient, it is not in an emergency situation. If you have a leg ulcer, or cancer, or a surgical wound that’s not healing as it should, then the community nurse is ideally placed to see to your needs. However if you have fallen and either can’t get up by yourself, or have broken your hip, then what you need is an ambulance.
This isn’t to say that comunity nurses don’t already keep people from going into hospital. Community Treatment Teams (CTTs as they are known in my patch, your acronym may vary) work hard to stop people with chroninc and acute conditions from needing to visit A&E. Unfortunately trauma is something entirely different to the heart failure, asthmatic and palliative patients that these teams see.
An ambulance crew are trained to deal with these acute traumatic incidents. Community nurses are not (as an aside there was some research about how nurses are really bad at first aid. And they are bad).

The plan is for a nurse to give a painkiller, including morphine, and then wait for the ambulance. At least I assume they are supposed to wait. I know I’m not going to give Doris with her fractured hip 10mg of morphine and then leave her on the floor. A big problem with this is that, as a community nurse, my day is already packed with patients (and as the government wants to kick more patients into the community, that will only increase). It is more common than not that I work through my lunchbreak, just in order to do the bare minimum for my patients. Community nurses do not have the time to play at ambulances.

What happens if the nurse overestimates the amount of morphine to give the patient, they’ll need a BVM, and training in how to use it and naloxone and how to give it, maybe some other drugs to counter potential bradycardia. And remember, a nurse doesn’t then have the option to load the patient into the back of an ambulance and whizz off to hospital. They’ve got to sit there.

And then who is going to supply the morphine, where will it be kept? Morphine is a Controlled Substance and needs to be kept in a special locked cupboard inside another locked cupboard. Who is going to provide a stock of morphine just in case it’s needed.

And then there is…

…but you get my point.

This is, yet again, an example of short-term thinking to patch up huge holes in the NHS that have been caused by successive governments. Both the ambulance services and the community nursing trusts need more money, and odd blue-sky thinking by people who are several steps removed from actually meeting patients is not the way.

Blogging, NHS

Post-Bingo NHS

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I took a look at my blog the other day. ‘Last post Jan 18 2016’, so nearly a year spent noodling around on Twitter rather than actually writing anything. I’d started a new job and that needed a fair bit of my attention, then there were games to play and food to eat and things to build. Then before you know it you’ve stopped writing and replaced it with reusing other people’s writing by ‘retweeting’ it.

Urgh.

No one reads blogs anymore, or so goes the common consensus, but when I use twitter I’m often redirected to a website, a blog or a whatever you call a Tumblr thing.

I also wasn’t angry. Well, that’s a bit of a lie. I first started writing because I was angry about things and writing about it got it off my chest. I’m still angry but I came to realise that not many people cared about the things I cared about, and so my writing didn’t exactly save the NHS, fix the planet or stop tech people from doing really dumb things.

But, maybe I do have it in me to write again. There are more and more stupid things happening, and while you may mutter about ‘echo chambers’ and ‘shouting into the void’, perhaps there might be a bit of value in starting to write again.

(If you are curious about the title, ‘bingo fuel’ is a term for the amount of fuel you need to land a plane safely. I’ve got a horrible fear that the NHS is past that point and is truely doomed. I hope for everyone’s sake that I’m wrong)

Burning hatred, NHS, Politics

What a Difference A Day Makes

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What a Difference a day makes.

On the anniversary of the 7/7 bombings,

In the Commons, MPs paid tribute to the actions of NHS workers and members of the emergency services in the wake of the bombings.
Speaking during health questions in the chamber, shadow health secretary Andy Burnham described the actions of NHS staff on the day as “heroic”.
Health Secretary Jeremy Hunt praised the “extraordinary bravery” of the emergency services.

And then one day later

Public sector workers, including civil servants, teachers, nurses, police officers and members of the armed forces, face another four-year pay freeze as a result of today’s budget.

Burning hatred, Health, NHS, Politics, Responding to media, TRUTH BASTARDS

Lord Warner – A Challenge

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Lord Warner has released a report stating that we should pay £10 ‘tax’ to use the NHS and that the NHS is ‘not cost effective’ despite all the evidence to the contrary. Both of these statements are frankly bollocks. However we have grown used to these lies and, as the media keeps pushing them, eventually they will be believed.

I looked up Lord Warner, he is the executive director along with a Suzanne Warner of ‘Sage Advice Ltd.’ A company that has no contact details, no website and no telephone number. At least none that I can find. This doesn’t mean that this ‘company’ is in any way dishonest, but as a simpleton in the ways of business I can’t see the reasoning behind it.

Of course, this, and Lord Warner’s previous job advising Apax Partners (a company that invests in private healthcare) might mean that he has some sort of vested interest in bringing about further privatisation of the NHS.

Sadly the newspapers only printed Lord Warner’s side of the story (i.e. Bullshit) and have not in any way highlighted these vested interests.

So, as I lay in bed trying to sleep but with sparking neurons of flaming anger keeping me awake I came up with an idea. It’s not a cunning idea, and Lord Warner would never agree to it, but it might be nice to dream.

You get a small, agile, hell – even amateur, filmmaker to stage an hour-long debate between Lord Warner and a defender of the NHS. They each have plenty time to prepare and can bring actual, real, evidence to defend their position – and this evidence is added to the debate, maybe even using whizzy computer graphics. Maybe there could be a referee who calls for the evidence to be brought out when one side or the other makes a statement and challenges the participants.

This film then goes up online where anyone can see it and we try to get newspapers (who really should be the people doing this sort of thing) to publicise it.

Every soundbite has to have evidence to back it up, there is no ‘playing to the crowd’, there is only truth.

Not that this sort of thing would ever be allowed – because Warner, (sorry, forgot the ‘Lord’ and tug of the forelock) already has all the power and this sort of truth finding would only have the risk of him seceding power to someone opposed to him. While the defender of the NHS has nothing to lose (except, y’know, the NHS) Lord Warner would have everything to lose by taking part in such a radical idea as a search for the actual real truth.

So, silly idea, but at least it gets this idea out of my head and onto the screen so that I can hopefully get some sleep.

Community Nursing, NHS

Why I Changed Jobs

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I’ve been trying to put into words the exact reason why I have left the acute services (A&E, Ambulance, Urgent Care) to move into the slower paced world of community care. After fifteen years of acute services you might think that it is because I have some degree of ‘burn out’, and maybe that is part of it. Perhaps it’s because I am getting older and more worn out and so the ‘easier’ work of a community nurse appeals to me.

I was visiting a member of the In-health team today and she asked me that question, why I am going from a band 7 job to a band 5, and why the sudden change of career.

The answer that I came up with while sitting in her office is perhaps the closest I’ve come to putting my finger on the truth. I told her that while in acute services, I may well be fixing people on the day, in this new job I would be able to help them for much longer and in a deeper fashion.

If you come to me with a broken arm I’ll assess you, x-ray your arm, give you painkillers, put you in a plaster and arrange the follow up appointment – I am unlikely to see you again.

Now I am working for the community, I will be coming into a person’s home on a regular basis and I’ll be able to provide a more in-depth service. If they tell me that they are having trouble with the stairs, I can arrange help with that, if they are feeling depressed, I can refer them to the right people, if I can heal their leg ulcer then that will make a massive difference to their life. Heck – if I can make sure that they always have incontinence pads in stock then that will make them happy. Instead of a rapid response I am better placed to provide care in more depth.

I was often asked what about the worst things I would see on the ambulances – people would expect me to talk about car crashes and dead children. Instead I would surprise them by explaining that the worst things that I saw were the old folks being neglected in nursing homes, or the housebound pensioner whose carers would drop their medication on the floor and not bother picking it up.

By moving to the community I will have more power to change that sort of thing for the better, in part because I am incapable of letting bad care continue.

That and I get more fresh air than working in the hospital.

Health, NHS

Kellett’s Laws Of Nursing

When I worked in the Urgent Care Centre I would often have student nurses spending their shift with me. Unfortunately for them I have many views and no shortage of desire to share these views with anyone within earshot. I’d also try to fit in some teaching if there was the time.

Over *mumble* years of nursing and ambulance work I formulated a few basics laws of nursing that I would inflict on as many students as I could catch. I never did get around to writing them down. Until now. 

Kellett’s Laws Of Nursing

1) Do Not Bullshit

If someone asks you to do something to a patient and you either do not understand or do not know how to do it then tell the person asking you. Do not under any circumstances ‘have a go’ and hope that it works out for the best. This is how you kill patients. For example if I send you to do an ECG (heart tracing) and you do it wrong I could end up sending them home without knowing that they are having a heart attack. I know it’s embarrassing to tell someone you don’t know how to do something – but it’s a damn sight more embarrassing to have to explain yourself to the coroner and the family of the patient you just killed. If you don’t know how to do something – don’t do it. Your biggest pressure is admitting a hole in your knowledge – and this ties in with my Fourth Law. This is how medical students were once trained – and look at how many people they kill.

2) It Hurts Them, Not You

Few people like to inflict pain on other people, but sometimes it has to be done. If I am sticking a needle in someone, it isn’t in the patient’s best interests for me to do this slowly and cautiously because I’m worried about hurting them because it will only hurt them more. What I often see is student nurses wincing before sticking a needle in someone as if they were about to inject themselves. Sometimes you just have to pull out that toenail despite the patient’s pain. (And yes, you can numb the toe – but that involves two injections into the base of the toe – and that really does hurt). What often doesn’t help the patient is if you are pulling faces, looking worried and being overly apologetic. Remember, it’s not going to hurt you – just do what needs to be done quickly and professionally and then get on to the next thing. Like wiping a bum, giving a suppository or examining someone’s genitals – it’s worse for them than it is for you.

3) Cynicism Kills Patients

I warn my students that they will either kill, or come close to killing, their first patient around two years after they have qualified. When they first qualify they are scared of doing the wrong thing, they will believe everything a patient says and will be exceptionally careful practitioners. Then their more qualified colleagues will start to corrupt them with their cynicism – ‘Oh he’s not in that much pain’, ‘She’s drug seeking’, ‘That’s not a heart attack, that’s attention seeking’. As we all like to fit into the social groups we find ourselves in, the new nurse will start emulating the more experienced nurse, specifically their cynicism. Unfortunately the new nurse does not have the experience of their colleagues* and so will dismiss a chest pain as ‘attention seeking’ and a patient will die. I like to err on the side of caution – if someone comes to me complaining of loads of pain and then skips out of the department after I’ve given them the good painkillers, then the only pain to me is my ego. Speaking of ego…

4) Leave Your Ego At The Door

Do you know what most complaints are to the NHS? ‘Attitude’. I’ve seen way to many staff get into an argument with a patient or relative because their ego will not let them back down. You do not need to ‘win’ your fights in order to do the right thing. For example – I have seen hundreds of patients who come to me in order to get antibiotics for viral illnesses. This is not only pointless but also downright dangerous. But most of them still leave the room smiling and happy despite my refusal to give them the antibiotics. I explain and if they argue I calmly explain again. I do not feel that I have to ‘win’, or prove that I am ‘smarter’ than them. The biggest obstacle in the way of calmly addressing a patient’s concerns is the nurse’s ego. My advice – the only way to win a primate hierarchy arguing game is simply not to play in the first place. I’ve been guilty of breaking this rule myself and it never ends well.

5) Anything You Do, Don’t Do, Or Do Badly, Can Kill Your Patient

It’s a summation of the above laws really but it does what it says on the tin. If you do something you might kill your patient. If you do something wrong you can kill a patient. If you do something badly… yep, you can kill your patient. So how do you stop from killing your patient? Simple – you pay attention, you do the best that you can for them, if you don’t know something then ask, if you are out of your depth then get help, and you keep learning and improving your knowledge. Treat each patient as if they were a beloved family member, or simply treat them how you would like to be treated. And if that doesn’t work then just imagine the Coroner or Judge staring at you over their glasses and asking your quite pointedly why you thought doing that was a good idea.

These may be a little tongue in cheek, and no doubt someone else has describe these elsewhere – but I think that you can avoid a lot of trouble if you just follow these laws.

Maybe I should expand these laws into a book ‘So, You Don’t Want To Kill Your Patient?’

*And age does not mean experience, as an ambulance driver will say you can have twenty years of experience, or you might have one year of experience repeated twenty times.

Health, NHS, Politics

Our New War

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The secretary of defence, Phillip Hammond, has stated that he will resist any further cuts to the armed forces. He said that the government’s priority was that they should be ‘defending the country and maintaining law and order’. He has said that the welfare should be cut by 0.5% in order to keep the armed forces at their current level.

The problem that I have with these statements is that ‘defence’ no longer means what it meant in the past. If you want to protect the people of Britain from death and injury then invasion from foreign powers comes pretty low down on the list of things we need to worry about.

Let’s take a look at the number of people who have died from ‘War’ in 2011 − 14 people.

The number of people who have died from infectious diseases is – 484,367 people.

By some coincidence the number of people who have also died from heart disease is – 484,367 people.

How about people who have died from just ischaemic heart disease? – 64, 435 people

How about the common type of age-related diabetes? – 1889 people.

Malnutrition killed 65 people in 2011.

Over four and a half times more people died of malnutrition than died in war. In a developed country.

(All numbers from the ONS – a fascinating read, although perhaps not recommended for hypochondriacs).

It is well known that poverty massively increases your chances of developing heart disease. Looking at a few studies, poverty pretty much doubles your chances of developing heart disease.

Poverty is one of the biggest influences on poor health, if you are a poor child then your risks of becoming chronically ill and dying young are greatly magnified.

Don’t take my word for it – google ‘poverty health outcomes uk’.

Our new war, from what we need more defence against, is disease. 

While I’m not going to argue that we disband the armed forces, our current threats are more terrorist than state-led. I doubt that the countries of the world are sitting around thinking ‘If only Britain didn’t have an army, we could roll in and conquer them completely’.  I’d suggest that if you look at the reasons given for the most recent UK terrorist attacks – it’s because we have soldiers in Afghanistan ‘protecting British interests’ by shooting at brown people that we have idiots blowing themselves up on public transport.

No, our biggest threat to life in the UK is disease the risk of which is increased by poverty. Poverty can be countered by welfare, which Mr. Hammond would like to see cut, and by the NHS, which is having it’s budget slashed while large parts of it are being sold off to private companies who want to make a profit from your sickness.

We need our ‘army’ to fight against what kills more people – disease, and by extension, poverty. At the moment the ‘slack’ in the system of dealing with disease is pretty much non-existent. Look at when one kebab shop was delivered contaminated meat – Seventy people became ill and made the local hospital declare an internal major incident. I know – I was there.

Now imagine what it will be like when the last antibiotics stop working, or when an influenza epidemic hits. We need to be investing now in order to save lives.

So instead of welfare and the NHS budget being cut so that soldiers can continue to war on the other side of the world, we need more effort to remove poverty from Britain and we need an NHS that will be able to cope with the incoming health crises that are likely  to be just around the corner.

Burning hatred, NHS, Politics

Nothing To Hide (Apparently)

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Remember when the government rolls out the fallacy of ‘If you have nothing to hide then you have nothing to fear’? They normally do this when talking about the ability to spy on all our emails and phone calls, install CCTV in our homes and other such privacy busting measures. After all, the argument goes, if we are all open and honest about everything then crime, terrorism and pedophiles will no longer exist.

(I’ll not delve too deeply into that particular fallacy)

Well it seems that they have not taken this motto to their own breast. Instead the government has decided to veto the information commissioners order to reveal the NHS Risk Register.

Let me explain the risk register, because part of the reason the government says it wants to keep this secret is because it is awfully complicated and it is unlike us mere members of the public could ever understand it.

The NHS risk register is how to measure the risk of something bad happening due to to governments changes. It does this by measuring two things – how likely something is to happen and how bad it would be if that something did happen. It measures both of these elements on a scale of 1 to 5 with 5 being the worst.

So for example – rating the likelihood of something bad happening, you would give ‘Being hit by a meteorite’ a 1 because it is incredibly unlikely. You would give ‘Being hit by a bus’ a 2 because it is more likely (though not common), and you would give ‘catch a cold’ a 5 because it is really quite likely.

Then you rate the impact that a bad thing would have, again on a scale of 1 to 5 with 5 being the worst. So ‘Being hit by a meteorite’ would be a 5 because it’s likely to kill you stone dead. ‘Being hit by a bus’ is probably a 4, it’s likely to do some lasting damage to you. ‘Catching a cold’ would be a 1 because it’s unlikely to do very much harm to you.

You then multiply these two numbers together to get the relative risk. So ‘being hit by a meteorite’ would be a 5 (1×5) because while it is really nasty it’s unlikely to happen. ‘Being hit by a bus’ would be a 8 (4×2) and ‘Catching a cold’ would be a 5 (1×5) because although it is likely in the wet and cold climate of the UK the actual harm is quite small.

These numbers are actually based on science, previous evidence and clever predictions- unlike what i have just done these numbers are not just plucked out of thin air. It’s a good way of managing and mitigating the harm of the risks involved in any activity.

That is the risk register in a nutshell. It’s the equivalent of buying a car after kicking the tyres and checking that it’s not two cars welded into one.

As the NHS reform bill went through the various stages of being voted on by the commons and the lords, a number of people who were to vote on it asked if they might actually look at the risk register – kick the tyres as it were. At each request the government refused. Why would the people voting for this legislation need to see if this car is a ringer? Don’t you trust the government? You must be some sort of Trotsky.

At one point in the lords, they actually voted against seeing the risk register. I believe this is the lord’s version of sticking their fingers in their ears and humming loudly.

The information commission, after a freedom of information request, ruled that the government should publish the risk register, the government then went to a number of different courts in an effort to not do this. However, none of the courts agreed with the government because, well, they aren’t idiots.

Yesterday the government invoked the nuclear option – a veto for ‘exceptional circumstances’. Stating that the reason for this veto was because ‘otherwise the civil service might tell lies if they realise that the plebs might look at their working out’.

Essentially the government is admitting that the risk register is full of 4×4 and 5×5 risks and that if the public were to see this then they might start questioning if the NHS reform bill was actually worth the risk. Why else would you work so harm to hide something if it’s contents were not explosive to your governing of the UK?

In the Queens speech today one plan was for ‘businesses to have less inspection’. Ostensibly so that they can get on with the business of making profit rather than, I dunno, being in compliance with the law. I suspect that this will apply to all those private companies taking over parts of the NHS – After all, actually inspecting them might show that the companies involved may not have their patient’s best interests at heart. And that would be damaging to the government.

I would be willing to put money on the risk register containing a 4×4 risk of ‘Private healthcare companies break the law and provide sub-standard service’…

 

This blogpost was written while listening to Rob Dougan ‘Furious Angels’