In the Midst of Life (29 page)

‘Oh my God! This book has gotta be written. We do it all the time. Hell, it’s crazy. We dialyse people who are ninety-eight per cent dead. They don’t know anything, can’t move, can’t swallow, can’t talk, totally incontinent, an’ we do renal dialysis, three times a week. Hell, it’s just crazy.’

‘Can you go on?’ I asked.

‘I tell you, we got a guy in our clinic at the moment with creeping paralysis – it’s got a lot of new fancy names, but it’s the same ol’ thing, creepin’ paralysis – starts in the peripheries an’ creeps up through the body, an’ when it gets to the lungs that’s it. Or it used to be. But not any more. This guy’s had it for two years, slowly, slowly losing all sensation an’ control, creeping slowly up, an’ it’s got to his lungs. So what do we do? Eh? We bring in a respirator. At the same time he loses control of swallowing – so we
pass a naso-gastric tube. It’s obscene.’ She had to pause before continuing and her voice became slower and sadder. ‘Poor ol’ guy, he was so sweet. It alters y’nursing perspective, y’know. When you’re looking after someone with Alzheimer’s or creepin’ paralysis, you build up a real relationship, with a real person. When it gets to a respirator and artificial feeding, you’re just maintaining a machine, and the person gets to be a chemical reactor. It’s not the same at all.’

The sunshine suddenly seemed less bright, and the Bay of Naples less beautiful.

‘Do you think profit is the motive?’ I asked.

She shrugged. ‘Your guess is as good as mine.’

‘When will it all stop?’ I enquired.

She was fierce in her reply.

‘I’ll tell you. It’ll stop when the money runs out. When relatives have to pay for it out of their own pockets. When they can’t demand that the insurance pays for it.
That’s
when it will stop.’

‘When the money runs out’! Great poets and writers and thinkers can express the inexpressible, and see way into the future. Samuel Beckett, in his book
Malone Dies,
published in 1951, wrote, ‘There’s no place in America where a man can die in peace and with some dignity, unless he lives in abject poverty.’

The possibility of extending life for long periods of time opens the door to exploitation, and I have a hunch that it’s possible a good many people might be kept alive for the money they bring in.

Look at it this way. Only a small number of nursing care homes are non-profit charities, and these are mostly faith-inspired. The majority of care homes are profit-making establishments, which can be bought and sold on the open market. Some of them are public limited companies, with a board of directors whose first responsibility is to their shareholders. Care homes can be very profitable, and it is alleged that some directors lead millionaire lifestyles.

Every institution, be it something like a school or a sports club
or whatever, relies on numbers to keep going. If the numbers drop, the institution becomes economically unviable. Private clinics, rest homes and nursing care homes, all of which rely on cash flow, are no different. They have to maintain a certain number of paying patients to keep going. A death represents loss of revenue. The more expensive the place, the more urgent the need to keep the beds filled.

Everyone I have tried to speak to on this matter shuts me up, or changes the subject. But body language is more eloquent than words. A sudden gasp of breath, a widening of the eyes, or tightening of the mouth, suggest that I have dared to broach a subject best avoided.

Betting has never been my obsession, but I would bet that my hunch is correct!

Half a century ago, there was no distinction between nurses and carers, because student nurses did all the work that carers now do. A young girl’s nursing training started with three months’ classroom induction. Then followed a full year of basic, hands-on, bedside nursing care – in other words, all the mucky work. Two more years of ward work had to be completed before State Registration. We were constantly under the strict supervision of the staff nurses, ward sisters and, ultimately, Matron – all of whom had been through the same training. It was a real apprenticeship.

But nursing was firmly stuck in the past, based on the old Nightingale tradition – docile acceptance of rigid discipline under a hierarchical system that was sacrosanct. Reform was necessary.

The Salmon Report (1966) appeared first, proposing new management principles for nursing. Some of these changes were undoubtedly needed, but I remember the shock that swept through the profession, and later the whole of society, when it was announced that the post of matron would be axed, leaving no one with overall responsibility for nursing standards.

1972 brought the Briggs Report. It proposed that nurses’ courses in further education colleges should be established. However, nurses were still working long hours on the wards, and if they left, someone would have to replace them. This problem was not, and has never yet been, adequately addressed.

The Griffiths Report came next (1983), under the chairmanship of Sir Roy Griffiths, the Chief Executive of Sainsbury’s, with a committee that did not include medical or nursing representation. The report recommended that management based on business
models should be introduced to save the government money. According to Griffiths, there should be no difficulty in transposing the principles of commerce to the NHS. Once you let economists and accountants get their hands on things, you quickly lose sight of the original objective!

Project 2000, 1986, was the work of a new statutory body, the UK Central Council for Nurses (known as the UKCC) who, with the Royal College of Nursing, debated the training of nurses. Higher education was becoming absolutely essential. One small example will suffice to illustrate this: in my years of training we had a few hundred drugs, of which about forty or fifty were in common use. Now, medicine has hundreds of thousands of drugs in its armoury, of which about one thousand are in daily use. They all have to be known – their dosage, action, reaction, cross-reactions, allergic reactions. If I were working on the wards today, with my level of knowledge, I would be a danger to the public! A good education is essential, to degree standard.

Project 2000 aimed to bring students under the aegis of academia, thus removing their isolation from mainstream student life, and enhancing the image of nursing as an academic discipline. This, in my opinion, is a wonderful aim. Project 2000 is lengthy and wide-ranging, mostly relevant only to the professions, but the following are three of the main features of reform that are pertinent to the care of the sick and ageing:

1. To separate education from service by conferring supernumerary status on students and creating bursaries in place of training salaries.
   
2. To create a single register that would do away with the Enrolled Nurse grade, and to simplify the designation of first-year student nurses.
   
3. To establish a new clinical grade of support staff, essentially to replace junior nurses and enrolled nurses, whose function would be fulfilled by these aides.
   

‘To
separate education from service’. Herein lies the rub. Nurses need higher education, but they also need practical training in bedside nursing. A thousand and one tiny details, some so small they are barely perceptible, are involved in basic nursing care, and these details have to be learned; they are not obvious to the casual observer or to someone who thinks they could just do the job.

The second reform dealt with the proposal to do away with the State Enrolled Nurse (SEN) qualification. Nursing staff had always had assistant nurses or auxiliaries to help them. The Voluntary Aid Detachments (VADs) in the military hospitals of the First World War are just one example. Later in the century, the SEN received a training approved by the Royal College of Nursing (RCN) that was essentially the same as the first year of student nursing. The course appealed mainly to married women who had family commitments, who enjoyed nursing but did not want responsibility. I worked with several and, as a ward sister, knew that an SEN was a great asset, providing stability and continuity on a ward. Also, she was often a mother figure to nervous young students, doctors as well as nurses. But Project 2000 looked ahead to a single register of graduate nurses, in which a second grade of enrolled nurses had no part.

When I read the words ‘To establish a new clinical grade of support staff,’ I was unclear what this might mean, but assumed it could easily be found out. Two months later, after an exhaustive study of professional papers and government reports, after rushing around all over the country interviewing people, I am still unclear, and get the impression that everyone else is, too!

Let’s start with the name or title for these support workers. My researches produced about twenty different names. When I told this to a spokesman for the RCN, he laughed: ‘Over the history of the RCN we have come up with 295 different names for support staff, and there may be more.’

From the inception of Project 2000, statutory powers enabled the UKCC to phase out the apprenticeship approach in favour of more academic training. Nurses started to leave the wards, and that was when carers came in. It was the first time the word ‘carer’ had
been used as a job description. Hitherto, they would have been called auxiliaries, assistants, or one of the 295 options. By the 1990s, the title Health Care Assistant (HCA) became accepted, and this seems likely to stick.

In my capacity as an ordinary person, or ‘Everyman’, seeking to get to grips with this revolution in healthcare provision, I studied a great many documents, Government Reports, professional reviews, websites and journals distributed for public information by the Care Quality Commission (CQC, formerly known as the Healthcare Review Body). Whilst the area is muddy and changing all the time, the following is taken from my researches and is accurate at the time of writing:

Question (from ‘Everyman’):
So who does the basic nursing these days?

Answer (information gleaned from CQC documents):
Health Care Assistants.

Q
: And who trains them – the RCN?

A:
No. The employer, the Trusts, the NHS Training Authority, the care home, the agency or an independent hospital.

Q
: What training could the Trust give, for example?

A:
This can vary. Some trusts offer up to six weeks induction and training, whilst others provide two weeks of support for new Health Care Assistants.

Q
: What training would a private hospital, clinic or care home give?

A:
There is no national standard, and on the whole it is very little, a couple of days at most. However, all health care workers must show the Criminal Records Bureau clearance, and complete a brief induction.

Dear Heaven, it can’t be true! And we had fifteen months’ training in basic nursing.

I have two nieces who are health care assistants. One of them told me that she had worked with disabled children, and decided to change to geriatric nursing. She said, ‘So the agency sent me on half a day’s training.’

‘What!’
I gasped. ‘You can’t be serious!’

‘Yes, that was it, half a day. But remember, I had had experience in caring, and I had done some home visiting, too. If I hadn’t, I suppose they would have sent me for a whole day, perhaps even two.’

So it
is
true.

Induction consists of three parts, which can be completed in a morning:

1. Fire drill, conducted by a fire officer

2. Moving and handling

3. Protection of vulnerable adults.

‘Moving and handling’ is instruction in how to use the winches, slings, pulleys etc., required for moving or lifting an immobile or helpless patient. Some of this equipment can be very complicated, and the company that makes these gadgets supplies a video instruction on the correct use. The purpose is to protect the employers and suppliers from claims of injury to nurses or care assistants from moving or handling patients incorrectly.

‘Protection of vulnerable adults’ is basically looking at different kinds of abuse, such as staff bullying or manipulating patients, or thieving. It is a video documentary, made by professional actors with advice and short, acted scenes of what can be done, and what one should not do. The purpose is to protect the employer from claims of malpractice. The video takes about forty-five minutes to run.

National Vocational Qualifications (NVQs) have been available since the 1970s. They are based on national standards of practical competence in a wide range of occupations (over 1000) varying from bricklaying to hairdressing to catering.

In 1988 the Healthcare Review Body (now the CQC) examined the position of carers, and, as a result, the NVQ training was started for prospective health care assistants. This is essentially a qualification in
practical
skills, and the training is on-the-job experience. There are three levels of achievement, trained, monitored and assessed by …

Question
(from ‘Everyman’):
… by whom?

Answer (from my research):
It could be that the trust has a nurse-led training, followed by supervision of practice by a qualified assessor, and then both internal and external verification by an awarding body such as the City and Guilds.

Q
: What is the training for care assistants in private hospitals or clinics or in nursing care homes?