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Shots Off-Target

September 16, 2014

Targets are in the news again. This time it’s in the guise of distressing stories about ‘community nurses’ approaching elderly and vulnerable patients out of the blue (or even cold-calling them) to ask a series of questions about their wishes and preferences in respect of their health care. One of the questions is alleged (by the Daily Mail) to be ‘Do you agree to a Do Not Resuscitate (DNR) notice?’. But if you thought that was bad, wait until you read the next bit. The whole point of the exercise (again according to the Daily Mail) is to enable financially-pressurised GPs ‘to compile a ‘death list’ which they can produce whenever the person falls ill or is taken to hospital’. Targets are part of the picture because under a new ‘Enhanced Service’ scheme, participating GP practices will receive payments depending on what percentage of appropriately-identified patients complete the questionnaire.

 
The distortions in the Mail‘s editorial are frightening. The laudable aims of Enhanced Service are to ensure a greater awareness of what people actually want and better integration between community and hospital. And what the form actually asks is whether emergency care and treatment has been discussed (‘No’ is a possible answer) and if so, whether the person has ‘agreed a DNR or what treatment should be given’. To me at least, the implication here is that any response would reflect the outcome of discussions previously held with friends, family and professionals, rather than knee-jerk reaction. And this is what the Daily Mail, in its usual headlong rush to blame everything on ‘callous health workers’, is missing: there is an onus on each and every one of us to consider the issues and make our wishes known before it’s too late. You can’t just push the responsibility onto somebody else and then hang them out to dry when it all goes wrong.

 
Amongst this forest of obfuscation however, one genuine problem is thrown into stark relief. Experiences documented within the pages of not just the Daily Mail but also the (hopefully) more measured Nursing Times suggest that in places the initiative really has been poorly implemented, leaving interviewees variously shocked, disorientated and distressed. This should make no one proud. But what struck me just as forcefully was the size of the box allocated for documenting the outcome of any discussion on treatment options. It’s tiny. It’s minute. Whoever designed it plainly had no idea of the complexity of feeling people might have on this issue, and what is more, they plainly had no idea about nursing either.

 
Nursing – what nurses do – cannot be conveniently reduced to some boxes and a series of yes/no answers. The whole ‘death list’ saga is merely the latest – and crassest – confirmation of that. The targets culture, with its emphasis on measuring, documenting and comparing for the purposes of ascertaining monetary worth, is essentially a model adapted from the business world in order to make the NHS function more like a market economy. Its fit with the traditional affective values of nursing is so poor, and its effect on those values so destabilising, that the National Nursing Strategy and love-’em-or-loathe-’em 6Cs had to be invented as a corrective. The 6Cs are, in effect, an admission of failure: an attempt to shore up nursing as it buckled under the logic of competitive health care.

 
That logic has distorted the profession by dictating what its priorities should be. ‘Bed management’ is a case in point. You’re a staff nurse on a ward. You arrive for work at seven or seven-thirty in the morning, get handover from the night staff, and then your manager appears. What’s the first question she asks you? Whose condition has changed overnight? Who needs medical review? Who has received an unfavourable diagnosis and doesn’t feel much like facing the world? Actually, none of the above. The first words you’re likely to hear are: “Any definites? Any potentials?” She’s talking about patients for discharge of course. So while nursing may congratulate itself on successfully banishing to the Naughty Step anyone who refers to elderly patients as ‘bed-blockers’, in reality it has merely substituted this term with ‘definites’ and ‘potentials’. In the conveyor belt-culture, everyone’s a unit of throughput.

 
As a result, nursing is being asked to reconcile within a single discipline two discourses that are fundamentally opposed: market economics and at the same time a more humane and time-consuming ethic of care and compassion. It’s no wonder we’re struggling. In the specific case of Enhanced Service, there is of course no excuse for insensitivity, and it’s upsetting to hear that nurses have been accused of it – but it’s also legitimate to ask questions. Whose targets are these? Were nurses involved in drawing them up and deciding how they would be implemented? Has there been sufficient training in their use? Have staff been given dedicated time to complete them, or are they just an add-on to everything else that has to be fitted into the average working day?

 
What has been abundantly demonstrated here is that hitting a target and the delivery of person-centred care by trained nurses are not the same thing. You cannot simply assume that compliance with one guarantees compliance with the other. Measuring the impact of nursing care has always been problematic, but attempts to deny this by subsuming nursing input within other outcome measurements are coming apart at the seams. Much of nursing care simply does not fit this model.

 
Pressure to act as agents for other peoples’ targets is undermining the standing of nursing; solutions however, will not be easy to find. While we may have ditched the doctors’ handmaidens tag, are we in danger of acquiring the new moniker of politicians’ administrators? One the other hand, financial constraint and rising demand for health services are not going to go away, and the public has the right to be reassured that nursing care at the local hospital or surgery is of the highest quality. For this to be a reality, some kind of measurement schedule is necessary and indeed inevitable. To stand aloof from that fact-of-life is to be pushed around by others.

 
Grassroots campaigns such as Stop the Pressure have shown that nurses can be energized by the prospect of delivering great nursing care. But we need to go further. We need to be develop a distinctively nursing vision of targets – demonstrating their effects on us as a profession and demanding an input in how they are set and delivered. Nurses should not have to apologise for talking to patients about the big and difficult questions; that is part of our job. But reducing it to a tick-box exercise is an insult not just us, but also to the lives and the humanity of our patients. That is what we need to be shouting about.

 

For the Daily Mail editorial, see: http://www.dailymail.co.uk/debate/article-2729408/A-callous-request-sign-life-away.html

 
For a Nursing Times article on the same subject, see: http://www.nursingtimes.net/nursing-practice/specialisms/end-of-life-and-palliative-care/community-nurses-under-pressure-over-end-of-life-chats/5074562.article

 
For the Enhanced Service document, see: http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/Enhanced%20Services/2014-15/Unplanned%20admissions/Avoiding%20Unplanned%20Admissions%20-%20Guidance%20and%20audit%20requirements%20for%202014-15.pdf

The Care Plan template is on page 32.

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2 Comments
  1. zoeharris13 permalink

    You make so much sense! Language is such an important building block in getting the culture right, but just changing the words (bed-blockers vs definites / potentials) is not enough to change the culture. And reducing big questions to yes/no answers is indeed insulting to all concerned. Targets need to be a lot more sophisticated than what you describe in order to accurately measure the quality of person-centred care.
    I always enjoy your blog – keep up the good work! Zoe

  2. Hi Zoe! Thank you for your kind words. Hearing that people enjoy reading what I write is wonderful and rather humbling, and makes everything worthwhile.
    Before I entered nursing, I had an earlier life as a languages student and I agree that language is fascinating and very revelatory of the assumptions that underlie the words we choose to describe our world. Of course, it is important that patients don’t stay in hospital for longer than necessary and that discharge is smooth and timely. But in order to conceptualise that, is there no alternative to the dehumanising language of the production line? It’s a good example of how nursing fails to ‘fit’ with prevailing discourses, and, consequently, struggles to make its voice heard.
    If you’re interested, my latest review of Great British Bake Off (viewable on The Egg Whisk, which you can access from this site), considers the meanings of some of the language used on Britain’s premier televised baking competition.

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