On conspiracies

I’m not a fan of conspiracy theories, while there is often a certain elegance to them I have been on this planet far too long to believe that great secrets can be kept. Humans are dreadfully inefficient creatures and a conspiracy needs a more perfect operation than can be handled by bunches of jumped up primates.

What I do see however is A leading to B which leads to C.

On Monday I wrote about the explosion in the use of private ambulances (and a good comment was left, one I shall revisit later), in that post I linked to my piece about the cutting of London ambulance staff by one sixth. A few days later, after the news story had been featured on the BBC, it was announced that London ambulance would be recruiting more staff.

Obviously I was interested, and as I keep an eye on such things, I looked as to who the LAS was looking to recruit. Their only job vacancies at the moment are for ‘Ambulance Support Staff’.

Ambulance support staff are not trained to the same standard as what the public would call ‘Paramedics’, and the plan is to team up one paramedic with a ‘support staff’. So when you call an ambulance only one of the people present will be trained to deal with your medical emergency. The other will essentially be a driver and equipment carrier.

It goes without saying that when there is a serious job, for example a ‘proper’ car accident, then you need all the hands you can get, and in the future you will arrive on a scene and half the people wearing green will be undertrained and underpaid staff.

Needless to say ambulance support staff are paid less than the person that they are sitting next to for twelve hours of the day.

So instead of the old ‘one day drive, one day look after the patient’ that we had always had, the paramedic will be looking after patients for twelve hours a day constantly with no break and no support. Given the unique pressures of ambulance work this is not in the best interests of the health of the paramedic.

Money will be saved, patients will initially not know the difference and paramedics will burn out even faster. These burnouts will be replaced by ‘apprentice paramedics’ who will also be cheaper than those who have been in the job for a longer period of time. What impact do you think that losing all your experienced members of staff will have on morale and, more importantly, patient care?

So we have a cutting of staff, followed by increasing private contractors and now followed by recruiting more staff. These staff are to be paid less than the staff originally lost. And apparently this will have no impact on patient care. The expensive staff will burn out quicker and be replaced by cheaper staff and this will mean patient care will fall.

This is similar to the government’s plan of student nurses working for a year as a HCA – it’s a blatant way of getting free (or certainly very cheap) health care assistants.

A leads to B which leads to C.

Private Ambulances

An apparent increase in the use of private ambulances in the NHS is a risk to patient safety, Labour has warned.
It says freedom of information requests show spending on private vehicles by three English ambulance services rose by millions over two years.

This is amusing to me as it was Labour who started the privatisation of the ambulance service whne they were in power. I remember the LAS losing a lot of patient transport contracts as private companies could ‘do it better and cheaper’. At one hospital I remember the private ambulance company lost their contract because none of their staff had been through criminal record checks…

I had reason to need an ambulance to transport a patient to hospital as an urgent case a little while ago. We booked the private ambulance to do the job and thought that was that. Later that day I had a phone call from the company saying that they wouldn’t do the job as it wasn’t booked with 24 hours notice. I told them that they should go ahead and book it for the next day, to which they replied that they still needed twenty four hours notice – I explained that they were actually getting twenty-six hours notice.

In the end we decided that as the patient needed to be in hospital we should use the LAS urgent service.
I was waiting at the house so that the crew could gain entry and was less than surprised to see a private ambulance turn up.

The figures showed an increase in spending of (in London) more then £3.8m, from less than £400,000, in 2010/2011, to £4.2m, in 2012/2013.

When I was still working in the hospital I was surprised that, when I went outside the A&E doors (normally looking for a member of staff who’d gone outside for a crafty cigarette), I would often see more private emergency ambulances than LAS ones.

As for the increase in private ambulances – could it have anything to do with something I wrote about previously – the decimation of the LAS?

While I am ideologically against the privatisation of the NHS (and the evidence would seem to back me up), the more practical concerns with respect to private ambulance services are, how well are they trained and kitted? Do they have clinical updates, CRB checks? Who does their staf training? What are the legal issues of them driving on blue lights and claiming the excemptions that the NHS services claim? In the effort to cut costs (and thereby increase profits for shareholders and owners) are they compromising patient safety?

I know that private ambulance services are monitored by the CQC, but we know how well staffed and effective they are.

The quality of the work of ambulance services are hard to track, it’s why the main gauge of ‘efficiency’ is ‘how fast did they get there’ – so I wonder how well the private services are being monitored.

My guess would be ‘not very well’.

My Nemesis In My New Job

I have been in this new job for about six weeks now and I have already come across the thing that gives me the biggest headache.

It’s faff.

For those who are unaware, ‘faff’ is the accretion of stuff that protrudes into our dimension after being summoned by excessive paperwork, awkward workflows and all those little things that go wrong and ruin your day.

Let me explain further – let’s say that I have to see a patient in order to dress a leg wound. Now, because of the rules every patient must have a prescription for the thing that I’m going to wrap around their leg, be that a clever hi-tech dressing impregnated with nano-particles, or a simple bandage. This is fine if the patient has a nice big box of the dressings in their front room.

Often they don’t.

So, for one pharmacy I can phone them up and they can order more, for the other two that we use I have to go back to base and order more using the victorian technology of a fax machine. Of course the nurse before me should have noticed that supplies were running low and would have done this previously.

This does not always happen.

It should also be obvious which pharmacy ‘owns’ the patient, but again, if a patient moves then the pharmacy that would logically be theirs, isn’t.

What this means is that I spend two hours running around (some would say ‘faffing around’) in order to scare up some dressings to use. And this is a simple example.

What it means is that a nice easy day turns into a nightmare as I faff about phoning referrals, chasing ambulances, robbing Peter to pay Paul and doing all those other things that are required in order to make sure that the patient gets the right care.

It’s not always incompetence which leads to the gathering of faff – sometimes it’s the pathways which we use. For the example above, why aren’t dressings automatically ordered? Surely we have the technology?

I think some of my workmates have seen that I’m starting to stomp around a bit grinding my teeth and muttering (who am I kidding, moaning) ‘why can’t things be better?’

My plan is to start trying to change things. Let’s see how it goes.

(Also – high degrees of faff from Squarespace v.6. I think I need to go back to v.5 which actually let me do things inside my blog posts)

TV On The Job

I was supposed to be writing more for this blog but a few things got in my way, mum going into and then coming out of hospital, new job, depression and being tired all the damn time. I’m going to try and make a bit more of an effort, not least because I’m supposed to be writing three things as well as this blog…


As I go from house to house visiting patients I catch a lot of snippets of TV. It is interesting to see what this tells me about my ‘client group’ (as is the correct term for patient now – it might be ‘stakeholder’ or some such, I’m afraid I lost track about three terminology changes ago).

The TV programmes that are being watched seem to fall into one of four things.

1) Jeremy Kyle.

2) Repeats of Catchphrase

3) A Bollywood/Asian soap channel

4) A Imaan preaching intercut with Asian political news.

I honestly do my best to not listen to Jeremy Kyle – I think about his show in the same way I would think about bear baiting if I lived in medieval times, its just an evil show. Catchphrase is pretty easy to ignore as he always seems to be talking to the contestants rather than getting on with playing the game. My favourite is the Bollywood/ Asian soap – it’s normally utterly insane. The other day I think someone had been bitten by a snake which had made them revert to childhood – at least that’s what it looked like to me, I’ve not much clue about what they are saying. Finally the Iman preaching is a pretty relaxing background noise unless you get one who likes shouting at the camera. The bonus of this channel is that I can now tell you what each Pakistani political party is now polling at.

Some patients will turn the TV off, others will keep it on and to be honest as long as I can hear what the patient client is saying, then I’m not much fussed.

Bad Nurses

The interrogator sat opposite the interviewee, his machinery sat on the table between them. He checked his screens with care, watching the pupil dilation of the woman he was addressing.

“Miss Jones”, he said, “You are walking in the desert and you come across a tortoise that is laying on it’s back in the baking sun. What do you do?”

“I pick it up and turn it over – poor thing”, she replied.

The interrogator made a few notes and asked her his follow up question, “And once you have completed your training and gained your degree?”

“Easy – fuck it, let it die”.

The interrogator stood and reached across the table to shake her hand, “Congratulations, welcome to nurse training”


The government has said that there is a problem with compassion in nursing, that nurses don’t ‘care’ enough. So today they released their plan on making nurses work as Healthcare assistants (HCAs) for up to a year before they start their training. Apparently this will teach prospective nurses how to care for people – something that I seem to remember from my own nurse training which didn’t include the HCA component. Obviously all nurses are horrible bastards while all HCAs are paragons of compassion and are never lazy or arrogant.

How much does the government value combatting the horrors of Mid Staffordshire? I their own words it must be ‘budget neutral’, in other words it must not cost anything. Which I think shows how seriously they take the care of the <strike>plebs</strike> public.

There seems to be the thought that, in the process of doing a degree, a prospective nurse has all human compassion removed from them. The person applying for a nursing degree may initially do so due to compassion for their fellow human, but sitting in classrooms, writing essays and going on placements somehow strips them of their empathy.

I also think that there is element of sexism in this anti-intellectual approach – nursing is still seen as a ‘woman’s job’, and the impression I get is that if we teach these women to a degree level then their wombs harden over and they lose their feminine caring. The discussion also seems to be around whether nurses really need a degree, after all can’t they just be taught on the job?

(The answer to that is no by the way)

However, it would seem that the government is sending a mixed message, first that educating nurses makes them into empathy-free robots, while they also want nurses to become mini-GPs (as I was) in order to provide primary care on the cheap. And if you think about it, if Cameron broke his ankle would he see a nurse practitioner, or would he see a doctor?

I think that this is also a way to get HCAs on the cheap – making students work on a ward in order to gain a bursary rather than ‘employ’ them with employment rights and pensions and all that sort of thing the government seems desperate to get rid of.

I wonder if further traction might be made of this idea. MPs lost their humanity years ago, probably as they start in a public school, go to a red brick university and then become MPs via a stream of ‘think tanks’, and consultancies. Perhaps they should spend a year as an HCA in order to remind them that voters are people and not just dots on a demographic graph. If you look at Jeremy Hunt and his actions, do you think that he cares for the person on the street?

I shall tell you why nurses appear ‘uncaring’, it’s because of the paperwork, the constant pressures, the cuts in pay and jobs. It’s because unless you are a nurse or similar then you don’t understand the stresses you are under. Patients think that the nurse is being dismissive of them specifically – not because she has seen patients like you for twelve hours a day for the past five years and really, you aren’t that different from those that came before you and eventually it can wear you down.

Obviously something needs to improve, For example Schwartz Rounds. But attacking nurses for being over educated rather than addressing the root causes is not helping anyone. (Although these attacks are presumably ‘budget neutral’).

This just continues the attacks on nursing that are happening on a regular basis and a cynical person (i.e. me) would suggest that this is the government continuing to soften up the NHS in order to make it easier to sell it for their mates because obviously the solution for uncaring nurses is to employ private companies to provide care. After all if there is one thing that we know is that an unfettered capitalist system looks after the weakest members of society.

Anyway – I apologise for the rant, I had a tiring day today as a nurse and that sometimes makes me grumpy and a bit incoherent.

Why I Changed Jobs

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.

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.

Who I Am, What I Do

My name is Brian Kellett and I used to write a blog under the name Tom Reynolds. The old blog went down when the company hosting it stopped running their blogging platform. I moved my old blog ‘Random acts of Reality’ to here. All of it is here but at some point I lost the commentors names. Sorry about that.

I used to work on the ambulances, then I worked as a nurse practitioner in an urgent care centre. Now I’m a community nurse, looking after adults.

This means things like giving eye-drops and insulin, dressing leg ulcers, and doing supportive visits for people with chronic health problems. It gets a bit more complicated on occasion but that is it in a nutshell. I do not give people baths or feed them as that is the role of social services and home carers.

Since changing my job, I plan on writing a lot more. This is because I’m working eight hour shifts rather than twelve hour ones.

I wrote two books – Blood, sweat and tea, More blood, Sweat and Tea and these were collected into one volume – Sirens. These books were the basis of the TV series ‘Sirens‘. It got cancelled after one series – sorry.

I have back problems, bowel problems and depression, along with other pains and failures. This makes life sometimes annoying by which I cope by being angry at things.

I’m in the process of working on a new book and on a secret project codenamed ‘Truth Bastards’ that may or may not see the light of day.

I spend too much time gaming and can often be found on Steam as bkellett. I am also spending a large amount of time playing Guild Wars 2 on the Piken Square server – mostly as Tom Weylan.

I tweet a lot as @Reynolds and I don’t use Facebook if I can help it.  I am too old to use Tumblr.

The best way to reach me is through email, or via twitter.

Paperless Fail

I have a slight problem in the way in which I conduct my life and the way in which it impacts my job.

For the past year I have been trying to go as paperless as possible, that means things like having utility and bank statements sent via email. For those businesses that don’t do email statements I scan them into my computer, file them away, back them up and shred the originals. If you want to see last January’s gas bill I can pull it up on my phone and show you. Likewise if you want to see a pile of shredded paper I can show you that.

The problem is that I have a new job (Something I’ll be writing about once my feet are under the table a bit more), and with a new job comes things like brand new ID cards, smart-cards, parking permits – that sort of administrative faff that is apparently essential but, for those of us not used to office work, rather annoying.

But why am I having problems? Well along with this faff comes the instructions on many of these forms that I need to provide ‘Two utility statements, a rent statement and a bank statement’, presumably to make sure that I am who I say I am and that I’m not trying to sneak away with a parking permit I shouldn’t have.

(As an aside – Newham’s business parking permit needs such specific forms of ID I’m surprised that they don’t also ask for security clearance from MI5).

All of which puts me in a bit of a bind because I don’t have any paper statements – I can show you my forms over the internet, on my phone or print them out for you – but if a bit of paper comes from my printer rather than the ones the energy companies use… well tough luck and try again.

This means that for part of today I have been emailing banks and utility companies asking them to send me a paper statement…

Paperless working – it only works as long as you don’t have to fill in any forms.

Our New War

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.

What Random Acts of Reality turned into