Francis cannot define compassionate care but we can still practise it

 Iain Wilkinson is an ST6 in the London Deanery and wrote the letter below for publication in the BGS newsletter

The second Francis report into the failings at Mid Staffordshire hospital will have stirred up feelings in a number of the readers of this newsletter. For me, I am actually quite anxious about the report. I see a number of things that happened at North Staffs that happen in every hospital I have worked in. The report shines a spotlight onto a number of areas of our practice as geriatricians and on-call general medical doctors, as highlighted by David Oliver’s excellent review (March 2013). Much of this is “structural” in nature (i.e.. training etc.). There are however some areas that are key to the way we work. 

It is said that the way a society cares for its older people reflects on the society as a whole. We need to look deep within ourselves, in our hospitals, and encourage our fellow physicians and surgeons to do the same to ensure we are truly providing ‘care’ for our patients. We live in a neoliberal society and as such, standards are set and assessed against and money follows these. This mindset is not going to change, and arguably it will become worse. In most hospitals, I think, on the whole we provide a good standard of care for our older patients but there is always room for improvement. Only this morning I was talking to the on-call team about the Francis report and they, unprompted, gave me examples from the last two days where incontinent patients had been left in pads when they were wet as “they are in pads, so it is ok” and where when one doctor asked if a patient could have another drink, the nurse replied “do I look like a tea lady?”. They assured me they got the drink themselves and arranged for the patient to be changed, but were still put out by this.

The report, I think, does highlight a key point which is that “compassionate care” is very hard to define and even harder to assess and as such hard to police / ensure / enforce. We assess what we can measure and we cannot really, reliably measure ‘care’ and so it is not assessed. The friends and family test is a step in the right direction but it is a crude tool at best.

I think “care” is taken as read with healthcare professionals but I am not sure it should be – most junior doctors and nurses these days have had relatively little exposure to care. Medical students often spend less than a month on care of the elderly wards in their training. There seems to be little leading on care. Ward sisters traditionally did the job but now they help patient flow, organise staffing, liaise with outside agencies, inside contractors, do audit, collect data to prove the ward is doing x, y or z. They are not therefore free to walk the ward, teach “caring” and enforce good practice (among doctors, nurses and AHPs). I try to provide all my patients with a drink every day on the ward round and make sure I leave them comfortable… but who will follow up on me if I don’t do this? Maybe ward sisters should not be the ward managers. I do not see why ward sisters should be doing the paperwork for the ward – that is not what they are trained to do but it happens everywhere and I was pleased to see this is reflected in the report’s recommendations.

I feel strongly that we, as Geriatricians,  are in a key position in the hospital and community environment. Personally, I feel the views of society to older people are changing for the better but it is a slow process and one that we as advocates for many older people need to continue to push forward.

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