Professor G. Clare Wenger
Emeritus Professor of Gerontology
During a week in which the NHS received much negative press coverage
(1-7 October 2007), I spent the best part of 6 days in a NHS General
Hospital. While the Government appears to be concerned with the numbers
of admissions, waiting lists, MRSA and cutting costs, very little
emphasis is placed on the patient experience. I would like to share my
experiences with you as objectively as possible, but first I feel a need
to present my credentials.
I am 71 years old and an Emeritus Professor of
Gerontology after a university research career during which part of my
energy was directed towards improving social policy and services for
older people. In the course of my professional career, I have visited
medical facilities in Australia, Canada, China, Denmark, France,
Germany, India, Japan, Sweden, Slovenia, Poland and the United States. I
have worked in a range of countries and have experienced conditions in
urban and rural China and India, so am not easily fazed by less than
optimum standards of cleanliness or privacy.
I serve on the North Wales NHS Research Joint
Advisory and Grants Committees and I am Chair of the Older People &
Ageing Research & Development Network (OPAN Cymru) Steering Group. I
served briefly as a non-executive director of the Oncology Unit at
Clatterbridge Hospital. I am on the editorial board of several
professional journals, including Quality in Ageing: Policy practice and research and Dementia: The international journal of social research and practice. I regularly review research proposals, research reports, papers for publication and abstracts for conference inclusion.
While I could afford private medical care, I
support the NHS and an integrated health service. I do not have private
health insurance on principle. I would wish that every person in the
United Kingdom received a high standard of health care, comparable with
other developed countries.
On Day 2 of my stay in hospital, the papers (Guardian, Daily Post and Daily Mail, which I read) reported that ‘in the context of Europe, the standard of health care in the United Kingdom comes 17th’, lower than some countries of the former soviet bloc. ‘Our
cancer survival rates are among the lowest in the world, our waiting
lists among the longest and our record on super-bugs and access to new
drugs and dentists is damned as ‘poor’ and when value for money is taken
into account, the UK comes 26th out of 29 in the league’ (Daily Mail, Day 2). It was also noted that more than half of patients in UK hospitals are dissatisfied.
General Practice
Generally my health is good but on 30 September I
experienced some rectal bleeding. On 1 October it was worse and I
telephoned my general practice. I was given an appointment immediately
without discussing my symptoms. The surgery is clean, well ordered and
offers electronic check-in in reception and computer records on the GP's
desk, added to during consultations. I was given a probable diagnosis
and advice and told that if the problem deteriorated I should go to
A&E. By early afternoon I was in A&E of the local general
hospital. I was admitted, put on a drip and restricted to only water by
mouth.
The envelope of the letter given to me by the
hospital on discharge to be delivered to the GP had the wrong address on
it. I needed to open it to ensure it referred to me and not another
patient.
Hygiene - Infection Control
I admit that I was anxious about being admitted
to this hospital. My mother had been admitted during her nineties on
several occasions. She had been very ill twice from hospital-acquired
infections and had on another occasion (aged 92) refused to be admitted
with a broken leg because she was afraid of further infection. Earlier
this year a friend had been admitted to the same hospital with a mental
illness, contracted a severe lung infection in hospital and died in ITC.
A life-long friend in the South of England, suffering from
non-Hodgkin’s lymphoma has contracted MRSA on four occasions.
It has been suggested that much of MRSA infection
comes from outside the hospital. All the more reason that people coming
in from outside should all disinfect their hands before they have
access to treatment areas. Within the last two years I had visited
patients in this hospital and had been concerned that there was no clear
point at which outsiders entering wards were expected to use
disinfectant on their hands. Since then there has reportedly been a
drive to enforce stricter hygiene standards. I expected to find
improvements. In my experience better precautions are taken to prevent
the spread of Foot and Mouth Disease.
I was therefore disconcerted to realise that
there was still no obvious place through which outsiders had to pass
where disinfecting their hands was expected. No bottles of hand rub were
clearly visible on entry to the ward although there was a bottle at the
end of each bed. However, I saw few visitors use it and some staff did
not use it either. It is important to stress that this was a surgical
ward reputed to be probably the best in the hospital (personal
communication from a consultant.)
Day 5 of my stay, the Daily Post ran an article headed ‘Ward sisters may get more power over cleanliness’. It was reported that ‘Hospital sisters could be handed more power to help fight infections’. Edwina Hart is cited as stating, “I consider a major part of a ward sister’s role is to improve the environment of care including the cleanliness of the ward…”.
I refer to this in the next section. However, it is the hygiene of the
whole hospital that needs attention before entry to wards is achieved.
Hygiene - Lavatory and Washing Facilities
I was asked to collect all my urine, faeces and
blood in a bedpan and hand each one to a nurse so that output could be
measured. There appeared to be four patient lavatories for a ward of 36
patients (females and males). Two were in cubicles with nothing else,
i.e. no way of washing and nowhere to put anything down - such as full
bedpans or clean clothing. Since I was bleeding, I tried to use a
lavatory with a washbasin, soap and waste bin in the same cubicle. Even
if these facilities were clean they would be inadequate.
In most instances, I needed to clean the lavatory
seat before I felt I could use it. The seat more often than not showed
evidence of urine or faeces, occasionally blood. Why did I clean it
myself? I did it myself because often I could not wait for someone to
come and clean it for me. There was often urine on the floor sometimes
starting to crystallise as it dried. Frequently, there were used
incontinence pads lying around and used toilet paper discarded on the
floor. The lid of the waste bin, occasionally overflowing or already
holding used intimate dressings, was the only dry place where anything
could be put down.
Subsequently, I was expected to take the used bed
pan to the nurses’ station and ‘hand it to a nurse.’ On most occasions
the pan contained badly smelling dark blood and blood clots. Sometimes
nurses took it from me, sometimes I had to ask a nurse to take it from
me, some nurses avoided eye contact, once I felt so faint and dizzy, I
had to put it down on the floor and once I had to ask a doctor to take
it from me.
For all visits to the lavatory I had to trundle
the stand for the drip with me. It was old-fashioned, heavy and the
wheels squeaked so loudly that not only did it draw attention to me
every time I went to the lavatory but the noise woke up other patients
day and night. As I became weaker it became heavier. This stand was
heavier and more old-fashioned than the one I had used in a Californian
hospital 35 years ago.
I felt that my squeaking drip stand made everyone
aware of my presence as I arrived at the nurses’ station with my bedpan
of foul smelling blood to wait for someone to take it from me often in
front of patients, porters and visitors. Luckily I am not someone who is
easily embarrassed but this was a thoroughly uncomfortable experience
exacerbated by my increasing weakness and dizziness and I did wonder how
other more sensitive patients might cope. By Day 5 I was off the drip
and discovered that the staff and visitors’ lavatories near the lifts to
other floors were marginally cleaner and stopped using ward lavatories
or bedpans and no one seemed to notice.
I felt well enough to take a shower on only 2
days after the drip had been disconnected. The shower cubicle I used was
dirty and the door was broken. The grouting was filthy and did not
appear to have been cleaned for a long time. No bath mats were provided.
There was one dirty plastic chair. On one occasion I had a bad bleed in
the shower. I cleaned away all the blood and asked the cleaner to
disinfect the shower, which she agreed to do. But what else from other
patients had only been flushed away with water? On both occasions I felt
I might faint and was forced to sit on the dirty plastic chair to
recover.
There were two washbasins in curtained cubicles
near one shower. These facilities were shared by the whole ward and some
of the other women repeatedly expressed their dismay that men walked in
on them when they were washing.
‘Ward sisters may get more power over cleanliness’ (Daily Post, 5 October 2007). Wrong! They may be given more responsibility,
but they have no power to change outdated and inadequate facilities and
however often they check they do not have time to check often enough
because the use by often very ill patients is heavy. Staffing levels
make it difficult for all clinical/nursing work to be accomplished. I
was told that the lavatory and shower facilities had not been improved
over the last 37 years.
This is a hospital in a rich developed country.
In airports and other public places in Europe, lavatories flush within
seconds of one standing up and a new clean seat cover rolls out to
replace the used one. But in this hospital there were not even any old
fashioned seat covers. On Day 1, a letter from Lord Roberts was
published in the Daily Post asking ‘why so much money is to be spent
on prestige buildings for the Welsh Assembly Government while the
health service in some postcode areas denies patients life-saving
treatment’. The fact that low budget cleaning and maintenance tasks cannot apparently be afforded is another problem.
Equipment and (minor) Material Resources
I have already mentioned the noisy and heavy drip
stand above. Later in the week, after I was off the drip, another
patient used it and it was still squeaking and she too found it heavy.
Oil would make the stands easier to move and quiet. The tables which can
be pulled over the bed were also very heavy and the wheels squeaked and
needed oil. Most patients could not move them. They were also
disturbing if patients were sleeping. An oil can on every ward would
help, would not need legislation and could possibly be absorbed by
existing budgets.
Bedside chairs made a loud shrieking noise when
pushed against the floor, but most patients were too weak to lift them.
This could be remedied by small pads on the feet.
I read a lot but the light over my bed flickered
all the time I was there. The NHS is to be commended on adopting energy
saving bulbs, but the fitments were not entirely compatible and that was
the problem I was told. I was told that they would ask an electrician
to come and look at it but no one came. Perhaps the Hospital Friends
volunteers, the Rotary, or some other charitable organisation could
raise the money to provide adequate and safer electrical connections.
Another patient had expected to be transferred to
a cottage hospital on Day 1, then on Day 2. She was dressed and ready
to go all Day 2. At 19.00 she was told that there was no ambulance
available to take her. She was finally transferred on Day 4. A relative
was prepared to take her by car but the rule is that such transfers must
be by ambulance. She had told me that she had only a short time to live
as a result of secondary and metastasized cancer and “I feel I am just wasting some of the days I have left”. She was, of course, blocking a bed in the acute hospital while another bed in the cottage hospital was being held for her.
A related matter is telephone use. Over the last
year or so, press reports have informed us that the use of mobile
telephones in hospitals is not hazardous for medical equipment. This
information had not permeated the hospital to which I was admitted.
Iconic signs forbade their use. When I enquired about this of the
nurses, they told me that this information seemed to be very slow
getting through and they were not stopping patients using their mobile
phones. Every day telephone calls for patients continued to come through
to the nurses’ station. This not only tied up those telephones, but
used valuable nurse time. Now that most people have mobile phones a
saving of time and energy could be made.
Treatment by Doctors
Overall I am satisfied with the medical care I
received. I accept that doctors have to see many patients, that medical
situations change from hour to hour or day to day, but I felt that I
could have been given better information or explanation at times.
I found it difficult to understand why it was
necessary, before I reached the ward, to undergo maybe 5 digital
examinations of my rectum. Did each doctor expect to find something
different? Had no doctor recorded his findings to share with others?
Were they students practising? How do more easily embarrassed patients
or patients in pain cope with this?
The more senior the doctor, the less likely they
were to introduce themselves by name. I had to ask who they were and the
response seemed to indicate that this was considered rather quaint
behaviour. A first response was, “I’m the consultant” and I had to ask
again for their name. They called me by my first name but introduced
themselves as Dr. ‘Whatsit’, giving no first name.
Day 1, I was told ‘you will need a sigmoidoscopy
tomorrow’. Day 2, as I recall I was told ‘you will have a sigmoidoscopy
later today’. It did not happen. Day 3, I was told that I would not have
a sigmoidoscopy as I was still bleeding and they would not be able to
see anything. I would be sent home when the bleeding stopped and come in
as an outpatient for a barium enema. I asked them how many days they
were prepared to wait. They seemed unsure. Something was said about a
transfusion if the blood count continued to drop. Day 4, I was told that
since the bleeding had not stopped, I was having the sigmoidoscopy
later that day, which is what happened. No mention of not being able to
see anything. By this point my confidence was undermined by what seemed
to be contradictory ad hoc reasoning. I raised this but received no real
satisfactory answer.
By Day 3, having eaten nothing since breakfast on
Day 1, as a borderline diabetic and still bleeding I was feeling
increasingly faint and dizzy. The evening before, I had been given a
sugary drink by the nursing staff because my blood sugar was down to 3. I
asked the doctors why I could not have food. They said I should have to
wait until after the examination. I could not follow their logic and
reminded them that they had just said I would not have the sigmoidoscopy
but was to come in as an outpatient for a barium enema instead. They
admitted that I was right and I was allowed to have food.
My confidence in medical decision-making was
being undermined. I had a lot of questions to ask before signing the
release for the procedure. On the basis of recent reports in the press I
needed to be reassured that this was the right clinical decision and
not a cheaper option. I no longer feel assured that doctors in the NHS
have the freedom (or power) to make the best clinical decision.
I have had diverticular disease for ca. 40 years.
They had told me that this type of bleeding usually stops of its own
accord. I was still bleeding. Recent press reports have noted money
saving clinical decisions. Would a scan be more appropriate than the
sigmoidoscopy? I needed to give informed consent and to understand their
logic. I was aware that a scan costs nearly twice as much as the other
procedure and I needed to be assured that the decision was being made on
clinical grounds. The doctor was very helpful, was not defensive and
reassured me. I watched the monitor and was able to ask questions.
Nothing was found except the old diverticular disease!
Treatment by nurses
For the most part I felt treated well by the
nurses and felt that most of the disappointments were the result of
shortcomings in the funding and management of the hospital. Often I did
not ask for help because it was clear that nurses were under stress to
get everything done and often there was no nurse around.
I had lost a lot of blood and the first night on
the ward I was cold. Eventually I asked for a second blanket. The nurse
was apologetic and explained that there were no extra blankets to be
had. I later discovered that many patients sent for blankets and pillows
from home because of shortages or low quality provision in the
hospital.
On Day 3 the 85 year-old woman in the next bed
could not eat her breakfast until she had worked hard to get the
attention of nurses to bring her her false teeth. As mealtimes have now
been made ‘protected time’ nurses were less likely to be available. On
Day 4, I did not eat my cereal because there was no milk available.
The woman next to me had been a nurse herself.
Every day she had to ask repeatedly for post-operative pain relief
because of shift changes. She complained vociferously.
Nurses clearly had assigned tasks. However, they
were often called away in the middle of performing them to help others.
They worked together co-operatively, but there were not enough of them
to meet all needs:
- On more than one occasion I was left with a
blood pressure cuff and finger heart rate monitor until a nurse
returned. During her absence the BP cuff pumped itself up three or more
times.
- Another patient had pain in her legs and was
offered a stool. It was ca. 36 hours before it materialised, during
which time she spoke frequently about her discomfort.
- I was bleeding heavily and thus drinking a lot
of water to counter thirst. A nurse said that she would fill my empty
jug one evening but I had no water all night.
- I had brought supplies of all of my
medications from home. When one (simavastin) ran out it was not
immediately refilled and there was none on the ward the next time it was
needed.
- When my blood sugar dropped too low I was offered a drink of Lucozade, but the nurse found there was none on the ward.
- When my blood sugar leapt up 24 hours later, I
was asked what I had eaten, but had only eaten the hospital diabetic
food. I think it was probably salad dressing and mayonnaise that were
probably not diabetic.
To me all these and other incidents indicate that not enough allotted time is being purchased by the NHS.
I was upset on one occasion when a senior nurse
reprimanded a less qualified nurse and a student nurse loudly in front
of patients. This was not professional behaviour and the student nurse
looked at me and seemed embarrassed.
I was distressed by the way the nursing staff
addressed patients, although after the first couple of days I recognised
that this is some sort of nursing micro-culture. The patients are
addressed as ‘my darling’, ‘sweetie’, ‘love’ and other terms of
endearment, not occasionally, but constantly. This seemed very
condescending and patronising to me.
The patronising approach came to a head when the
Sister/nurse in charge of the ward reminded me in front of doctors that I
would be going ‘for a look up the back end’ (or words to that effect)
with appropriate hand gesture. When challenged, it was suggested that
some people might not understand medical terminology. I pointed out that
I had observed patronising attitudes to other patients and to
less-qualified and student nurses. After a defensive response initially,
this was later acknowledged and accepted.
On Day 3, a woman was admitted to the bed
opposite me from a psychiatric unit. I have no way of knowing, but from
her body language and demeanour, I guessed that she was a long-term
patient. It was soon very clear to me that she was a Welsh speaker who
was less comfortable in English. However, there was only one nurse who
spoke to her in Welsh – and none on the night shift. Most of the other
patients and nurses ignored her. I went to speak with her and because I
pronounced her Welsh first name correctly she broke into a smile, but
was then monosyllabic when I tried in English to ask how she felt. She
looked sad, lonely and distressed.
The mentally ill woman (I will call her E) was
restless and got into and out of bed frequently. Occasionally she
wandered towards the nurses’ station opposite. During the night between
Days 4 and 5, I found it hard to sleep as there was loud conversation
going on at the nurses’ station. E. kept getting out of bed and heading
for the lavatory holding up an incontinence pad in front and behind. No
knickers had been supplied. She was repeatedly told to ‘get back into
bed’ and ‘go to sleep’. Not only did this keep all the other patients
awake but in my case I felt increasingly disturbed and upset at the way a
vulnerable woman was being treated.
At the end of the day shift of Day 3, I became
aware of the fact that one senior nurse remained on the ward. Two night
shift nurses – I think one SEN and one student – tried to persuade her
to go home. She said that she was not prepared to leave them without
adequate cover as she had realised that it could be a difficult night.
If necessary, she said she would stay all night. She telephoned nurse
management but was told that there was nothing that could be done and no
nurses were available. She then telephoned other wards. One ward
offered a student nurse for one hour for ‘settling down’ and another
ward said that a trained nurse from there would visit the ward at
regular intervals throughout the night in case there was a crisis. She
went home late but was back before 07.30.
Many nurses demonstrated dedication to their job
and loyalty to their colleagues. I heard nurses urging nurses who were
not well to go home and go to bed. Some were told they should have
stayed home to take care of themselves. There was apparently some sort
of ‘flu’ going around. Sick nurses insisted on coming in and staying to
the end of their shifts because their colleagues would be even more
short-staffed if they were not there. Nurses I know personally tell me
that they have been telephoned by management to ask them to come in even
if they are ill. Taking time off to be sick is apparently not seen as
acceptable behaviour.
Bear in mind that this was a surgical ward with a high need for asepsis.
Response to Psychological Stress
By the early morning of Day 5, I was very
distressed and depressed. I had slept little. I felt weak and unsteady
on my feet. I felt that the lack of cleanliness of lavatories, washing
facilities and showers, the hit and miss of hygiene measures and the
general risk of infection in hospitals were a threat to my increasingly
vulnerable state. I felt I needed to get out. I approached a nurse to
arrange to self discharge. I was told I had to wait for the day shift. I
felt suicidal and angry – but the bleeding was diminishing. By now
acting irrationally, I checked the exits and found that fire doors were
padlocked.
Just being in a hospital where my parents, my
husband and friends had been very ill, even though they did not die
there, was upsetting. I kept thinking about the hospital infections my
mother and my friend had suffered. I felt guilty because my children
were worrying about me. I was concerned about the way other patients
were being treated. Having worked all my professional life in the area
of social policy and the care of older people, I felt heart-broken to
find that conditions were if anything worse than they were 25 years ago.
I felt that my efforts had been futile.
Both doctors and nurses were very supportive and
kind, reassured me of my right to leave but tried to persuade me to stay
for 48 hours without bleeding. I negotiated it down to 24 hours and in
the afternoon agreed to stay for 24 hours. On Day 6 I was allowed home
in the late afternoon.
Discussion
The UK Government is reported to be increasingly concerned with human well-being (The Guardian,
5.10.07). Politicians and policy makers, too, are rethinking what
government can do to make people more positive (op cit.). This is
apparently to be achieved by reducing consumption. Many ways in which
the well-being of hospital patients can be improved are self-evident
from my experiences. I find myself with little faith that improvements
will be made.
Visible lack of hygiene measures and dirty
facilities, together with the recent experiences of family and friends
resulted in my decision to discharge myself irrespective of the impact
on my health. When my mother refused to be admitted due to her fear of
another infection, I was subsequently told by the general practice that,
since she had refused hospital admission, she was not entitled to
community care. I asked the doctors about this and they assured me that
it would not affect my future care.
NHS patients who complain about a poor standard
of care are at risk of being victimised health inspectors warn today,
after the first national audit of the complaints system in England (The Guardian,
8.10.07). My mother’s experience suggests that the same is true in
Wales. In England it was found that no hospital had comprehensive
safeguards to ensure that people who complained could be confident their
care would not suffer as a result. To be fair to the nurses and doctors
I complained to, they were not only sympathetic and understanding but
recognised that my complaints were valid. They appeared to be equally
frustrated by the poor level of service.
In writing this report, I do not intend to
criticise individual members of staff. I find it heart-breaking that a
national health service, of which the UK was once so proud, has reached
such a parlous standard. The Government has suggested bringing in
private companies to solve the problems of the NHS. There are many other
European countries with national health systems from which the UK
Government and Welsh Assembly might learn, including low budget
countries which have achieved a higher standard of health care, such as
Estonia and the Czech Republic; and better value for money such as
Bulgaria, Poland and Latvia. As one of the richest countries in the
world, the UK should aim to provide one of the best health care systems
in Europe.
End of Policy and Practice section