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Hello,

A frequently updated personal blog, but mostly friends-only. Please feel free to add me, however. 

Hever Castle

Knights at Hever Castle.

Four glorious nutters hamming it up for the crowd at Hever Castle last weekend.

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Filipino healthcare workers and supporters protesting against derogatory xenophobic articles published by the Daily mail. Outside the Daily Mail"s HQ, Northcliffe House, London.

I joined Filipino healthcare workers yesterday protesting outside the London HQ of the Daily Mail, after that newspaper published a derogatory, xenophobic article about Filipino nurse recruitment to the UK.
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St Mary's Redcliffe, Bristol.


Splendid, large, mostly 14th century.

Must be really, really annoying to have worked your way up to the position of Admiral, sailed all over the Med and the Caribbean, supported both sides in the Civil War and somehow got away with it, fought the Dutch and even killed the commander of their fleet, become a member of parliament, been knighted, featured in Pepys's diary, and then after all that tourists only come and photograph your grave because you have the same name as your kid who got famous in America.
Under the leadership of Professor Sir Mike Richards, in 2014 the Care Quality Commission adopted a new strategy for carrying out hospital inspections, recruiting large numbers of clinicians of all grades, and ‘expert by experience’ members of the public to assist as ‘advisors’ on inspections. This has been dubbed ‘Mike’s Army’. As an HR-trained staff nurse, nursing officer of my UNISON branch, with a great interest in safe nurse staffing and a staunch supporter of the 4:1 campaign, I was eager to join up. My application was accepted and I took part in my first inspection in October 2014. However, initially very excited to be involved, as the inspection progressed I came to the chilling conclusion that the CQC’s narrow remit and the attitudes of many of its inspectors/advisors leaves the nursing profession a sorely marginalised irrelevance.

A CQC team is composed of a core of professional CQC inspectors and a larger number of ‘specialist advisors’. The inspectors on my team came mainly with senior nursing or medical backgrounds, though not all. The specialist advisors were (like me) seconded from their day jobs and, like the inspectors, had mainly senior medical and nurse manager backgrounds. It was difficult to distinguish between the inspectors and advisors, in fact. One of our advisors was a surgeon formerly sacked by his NHS employers for whistle blowing, a heroic character indeed and also the most willing to listen, I found.

Looking first at an inspection team’s remit; their focus is compliance and outcomes and their job is to produce a rating. This next part is dull but important. A trust is scored using a system based on Ofsted’s (outstanding, good, requires improvement or inadequate) across five ‘domains’ (safe, effective, caring, responsive and well-led). During a hospital inspection the team splits into divisions (medical, surgical, critical care, maternity etc.) and each scores its division in the five domains. Crudely, the score averages out. If a division scores ‘good’ in three out of five domains it will score good overall. However, the ‘safe’ domain acts as a kind of trump card. Inadequate in the ‘safe’ domain means an inadequate overall score no matter what. For those of us campaigning for safer nurse staffing this is worth noting. At the end of the inspection the inspectors report back and arrive at a final score for each division and a hospital-wide score for each domain.

This is where nurse understaffing begins to be obscured. The focus of an inspection is compliance and outcomes. Ward managers are grilled for their data; infection rates, pressure sores, falls, mandatory training, ICNARC data etc. They have to prove that policies are up to date. Paper or electronic evidence must be produced. It’s not optional. For the buildings engineers it’s even more clear-cut. If evidence of statutory maintenance cannot be produced it’s illegal to use that equipment. It’s as simple as that. It’s very black and white. However, there is no legal regulation of nurse staffing ratios. There’s no compliance for the CQC to inspect.  The CQC will flag up more than 20% agency staffing on a ward (again, worth noting) but otherwise nurse understaffing is examined only as a possible factor effecting outcomes. In the absence of regulation the CQC requires actual evidence of negative outcomes and of causality. The oft-quoted mantra of CQC inspectors is ‘so what?’ Something might look bad but you need proof it’s bad. That a ward is missing 30% of its trained staff on an average day isn’t enough. This places the burden of producing negative evidence on staff alone, which is an impossible task when faced with executive managers doing everything in their power to produce positive evidence.

Let us here refresh our memory of the executive summary of the Francis Report:

“An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.”

In fact, nurses themselves unwittingly contribute to this culture of positive information. The employers are surely aware of this phenomenon and how it works in their favour during CQC inspections. Nurses on a ward where understaffing has become normalised will find ways to work around it, often at great cost to themselves, in order to maintain patient care. Good managers will foster a team spirit. If they’re skilled and lucky they’ll scrape by with few ‘serious incidents’ logged. When inspected by the CQC nurses will make an effort to present their unit in a positive light because, perfectly understandably, nobody wants to be blamed for or associated with a hospital ward deemed inadequate. When questioned by CQC inspectors, patients and relatives, aware of short staffing, will generously commend nursing staff. As a result that division might score ‘good’ in the safe, caring and well-led domains; enough to score good overall. The trust gets away with it and understaffing continues as normal. I think this raises questions about the way nurses interact with CQC teams. Do we really want them to see us hard at work or should we be downing tools and, in the politest way possible, confronting them about staffing levels?

My CQC experience turned sour for me from the first teleconference prior to the inspection. Teleconferences are the CQC’s preferred method of preparing specialist advisors. There are no face-to-face interviews and there is no real training. They opened by telling us the trust we were going to inspect was a good one and the management were confident we were going to give them a good rating. I interjected immediately pointing out that we hadn’t inspected it yet, so we couldn’t say it was good, and that the trust’s public data showed an average of 18% unfilled trained nurse day shifts. Executive managers always say they’re doing a good job unless it can be proved otherwise. Note again the Francis Report’s comment about institutional cultures of positive information. Have these professional hospital inspectors not read it? I then asked if I could see a full ‘hours planned and achieved’ staffing breakdown. This is easily obtained information that has to be collected under the new ‘hard truths’ requirements. Indeed, it is downloadable from the public website of my own trust. I was told to email the team leader and request it. This data was never provided to me, though I pestered for it several times throughout the inspection.  I was politely brushed off and reminded that understaffing was “just part of the wider picture”. True enough, but apparently only a very tiny part of the picture for the CQC.

Day 1 of the inspection was for preparation at the hotel. The trust’s chief executive, chairman and chief nurse gave a very corporate-styled presentation and then left the room. The experienced members of the CQC team took it with a big pinch of salt. It was resolved to pick up a few of the CEO’s claims and test them later. I expected a presentation by the trust’s main trade unions or staff side committee but there was none. Why does the CQC not actively seek out negative feedback from staff organisations? Why is positive information given such space? As the day progressed I became more eager to know exactly why I had been invited. If I was an ‘advisor’ when would I be asked for advice? As it turned out, that would be never. A junior staff nurse ‘specialist advisor’ on a CQC inspection team is expected to act as nothing more than a clerical assistant.

On Day 2 the inspection commenced. My training finally took place, in the taxi to the hospital. I was to make observations and ask staff questions based on a framework built around the five domains. This task I carried out mostly alone. It was very easy and quite entertaining. As well as severe understaffing I soon learned from nurses at the trust that it operated a ban on overtime pay, preferring instead to use bank, leave shifts empty or use more expensive agency staff. In some wards the trust was using up to 70% agency. Surely this favouring of agency deserved investigation by NHS Fraud? I raised it at the CQC team meeting later but heard nothing else. I raised it with the lead inspector on the surgical team but he appeared to misunderstand “the nurses would probably be too tired to do overtime anyway.” I raised it with the heroic whistle blower over dinner and he agreed spending on agency during an overtime ban, with thousands of hours of nurse shifts unfilled every month was nuts. Another part of the CQC team discovered that the Chief Nurse was not even able to exercise decisions about safe staffing, that being in the power of the Director of Operations. The Chief Nurse’s lack of power provoked chuckles. The inspectors were sympathetic but not surprised. I left the meeting with unanswered questions. Should the Chief Nurse not have whistle blown concerns about safe staffing? Should the NMC not be informed by the CQC if a Chief Nurse fails to do this? Apparently not the concern of the CQC.

The remaining two days were more of the same. In the brief time I spent with other inspectors I gained some interesting insights into their world view. One was very keen to see satisfaction and performance survey results pinned up on waiting room wall. I asked how the CQC would know if such data was real or faked-up. “It’s real data because an outside company does it” I was informed. Well, that’s alright then. Talking more generally about the NHS another told me “of course, society can’t really afford this anymore”. Really? There was also much banter within the team about the quality of the accommodation and the food laid on by the tust for our lunch and they talked a lot about how intense the work was. I understand that this was just innocent chat between colleagues, but could the former nurses on the team not remember doing the 12-hour shifts, having to work through unpaid breaks or eat an unpaid lunch in some horrible little inadequate staff room? I felt embarrassed. The prize, though, goes to an inspector with a nurse manager's background.

“All nurses feel understaffed all the time” she told me, “they tell you they’re understaffed, but of course they’ve got time to stand there telling you this.” Ah, silly me, being blinded by staffing data and lazy nurses!

This inspection was a real eye opener for me. I believe the CQC has recruited some brilliant minds. I was impressed by the expertise and tenacity of the medics on my team and I do not believe that they gave any senior doctor or middle manager an easy ride during this inspection. Anomalies or gaps in essential clinical data were sniffed out.  As a regulator of safe nurse staffing levels, however, the CQC is a lost cause. Partly this is not the fault of the CQC; no statutory minimum staffing ratios exist by which the CQC can measure compliance. Empty shifts are not illegal. However, its inspectors, even if they admire nurses paternalistically, do not regard nursing as a profession which should be empowered to set standards independently of employers, which in essence means nursing is not regarded as a profession at all. If the public are to be protected against unsafe staffing levels it isn’t the CQC that is going to do it.
 

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Initial Problems

A colleague at work was telling me that her father attended a posh boarding school when he was a boy and that at this school it was a strict rule that all pupils had their full initials stencilled onto their PE kit bag in big letters. His name was Steven Howard Ian Thompson. 

Golf

A young doctor at work was telling me she tried palying golf once but about halfway through her ball somehow landed right on the head of a female duck that just happened, at that very second, to be leading her ducklings across the fairway, killing her instantly. 
Fireplace with antique Benin bronze leopards and ivory.

I found this photo, with the stamp of photographer J.Cecil Gould (of Weybridge) on the back, in the flea market in Brighton and, Googling around, found the same pair of Benin bronze leopards in a Royal Academy exhibition two years ago. They are now back in the national museum in Nigera. The altar piece in the centre is in The Fowler Museum in L.A. and the central plaque is in the Musée du quai Branly in Paris. They are Benin artefacts originally looted during the 1897 Benin expedition. It was suggested this might be the home of collector W.D. Webster, who lived at 24 Palace Road in Streatham, London, which has since been demolished, but more likely is the house of George W. Neville, who lived at Wey Lea, Weybridge (see recent photo below). J. Cecil Gould was also based in Weybridge, so that provides a tantalising link. Neville's collection was sold off in 1930 after his death and a specialist at the British Museum believes that the leopards, the two plaques and masks on the fire hood are described in the catalogue of this sale. George Neville accompanied the Benin expedition and later a Captain Shelford wrote about him returning with a remarkable collection of curiosities; ‘They are in his house to this day, and include ivory tusks, carved and plain, two magnificent bronze leopards’. I can see this photo is going to be entertaining me for months....

Thanks to Susan Kloman, Hermione Waterfield, Tim Teuten, David Noden and Bruno Claessens for taking an interest in this.
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Purple Cherokees

Purple Cherokee tomatoes

My purple cherokee tomatoes didn't turn our quite as purple as I'd hoped but they're very edible. A small greenhouse in south east England probably isn't their optimal environment. 

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O2 / Millennium Dome. London.
The venue. Renamed after its current sponsor but I still think of it as the Millennium Dome. I last visited it when it was a shiny new rather eccentric white elephant of a previous government. It's faded a bit now, like me, and its neo-modernist forms are almost weather-beaten enough to pass as actual decayed 1960s modernism. There is a newer cable car over the Thames next to it, which has also proved a commercial white elephant. I couldn't resist it, of course. So, with a few hours to spare I crossed over industrial wastelands and the old Golden Syrup factory to what used to be docklands and is now a sterile, expensive housing estate, mostly devoid of people. It made me feel sad. An experiment in wealth attraction that has failed to attract anything other than wealth. I rode back over to the Dome in search of human life and found it heaving with 20,000 fellow Monty Python fans queuing for food and beer, and giant neo-Victorian Terry Gilliam sets. Yes! Then it began.....
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