Opening the doors to Panorama

PANORAMA.jpg

Old age and social care. It’s coming to us all. If we’re lucky. But it’s still something that rarely gets talked about until people are in the midst of it. What does it really look like at the sharp end? What does it cost? Who pays and who’s responsible?

‘Bringing social care to life’ was Panorama’s main aim when they pitched the idea of following our adult social care teams. To tell the human stories of those receiving care, their families and the staff working to support them, and show the decisions that have to be made in a system for which funding has lagged chronically behind the growing demands and expectations of an ageing population.

They arrived intending to spend three or four months producing a half-hour programme. Ten months later they were on their way with material for two, hour-long films that are being broadcast on 29 May and 5 June.

I implore you all watch them - first and foremost as ‘punters’. Together these films amount to the most un-airbrushed look at care and ageing I can think of. They are moving, powerful and thought-provoking. I challenge you to watch them and not come away having a quiet word with yourself about what it all means for you and your loved ones.

Secondly, watch them as people involved in local government communications and see if you can use them to tell your story about social care, how important it is and how it needs to looked after if it’s going to look after us.

This isn’t a Somerset story, it’s a national one. The stories you’ll see could have been filmed anywhere in this country and the issues are relevant to every community in the country.

Panorama came to us largely because of our demography. In ten years’ time, nearly 30% of Somerset’s population will be aged 65 or older (compared to 21% nationally) and in some parts of (stunningly beautiful) west Somerset, more than 50%. But this ‘age bomb’ is in the process of going off across the country. The over 65s make up 18% of the UK population, in ten years that will be 21% and in twenty it will be 24% - an extra 4.5m older people.

We’ll be coping with this first, but it’s coming to your way soon.

Everyone knows social care is underfunded. By LGA estimates the adult social care funding gap will be around £3.5billion by 2025. Yet, successive governments have failed to grasp the nettle that is coming up with a long-term plan . Five deadlines for the much-anticipated Green Paper have come and gone.

Future funding of social care seems to have gone from being something that was ‘too big to be ignored’ to being something that’s ‘so big it has to be ignored’.

We didn’t choose the title ‘Crisis in Care’. Care isn’t in crisis in Somerset, but the absence of editorial control was always part of the deal with Panorama. What there is, is an impending national crisis.

Staff come across wonderfully - compassionate and passionate, whether it’s our social workers, our care providers, voluntary groups and others involved in the health and care system.

But these films are about the harsh realities of a system that desperately needs a long-term fix rather than unpredictable presents from the Chancellor’s box of tricks.

This isn’t a ‘puff piece’ for social care, more an S.O.S. from the BBC on behalf of the system and everyone who works in it and with it. At an advance screening at BBC Broadcasting House, Sir Andrew Dilnot, someone who well knows the strains on the care system, was moved to tears.

Opening the doors to Panorama was not a decision taken lightly. We understood the risks of letting a hard-hitting documentary team ride shotgun with a service that looks after vulnerable people at a time when money is tight. A service that, even when everything works as it should, is full of emotive stories and expectations unmet. Then there were the practical implications for our staff doing their job with the film crew in tow. It took a lot of patience and good will from a lot of people to make this work.

But we took the decision that this was worth it – a rare opportunity to play a part in something that could stimulate a national debate and influence decision makers. If we’re asking others to take action, we felt we had a responsibility to do something ourselves.

It was a leap of faith, but we have an infectiously upbeat Director of Adult Social Services and a CEO and Leader who appreciate the bigger picture and the importance of looking out and not just in. We also have confidence in the work that we do and the staff who work for us. We are comfortable being the standard bearers for social care and pushing the need for a financial fix and a wider conversation about the future of social care.

We think this could help kick-start a long-overdue public debate about the future of social care and people’s expectations – of the ‘state’ and of themselves. What role in care should there be for families, for communities, for neighbours? That’s something for society to decide, but if the answer is ‘less and less’ then this daunting challenge will become impossible.

To make things more interesting, Panorama were here for the toughest budget-setting process that anyone can remember, at a time when the media was desperate to label someone the ‘next Northamptonshire’. So, they were here for the tough meetings, putting a high-definition lens in the Leader’s face minutes after an exhausting and emotional six-hour meeting. What they weren’t here for was the balanced budget, topped up reserves and financial stability that followed later on. There was a regular need to reassure those partners who were happy to take part in some of the filming, and manage the occasional friction with partners who weren’t, when the crew wanted to access to meetings. It’s annoying that what didn’t make it to the screen is all the great, innovative work we’re doing. We’ve got 92.7% of care providers Good or Outstanding, ground-breaking work in community-led care and massive reductions in delayed discharges from hospital. None of that makes it on screen, but this was always going to be a piece about the challenge.

There are parts of this that will make us uncomfortable. We’re not perfect, the system is complicated and we don’t always meet people’s expectations. But the overriding message that people should come away with is that social care is absolutely fundamental to the fabric of our society. It works because there are great staff, great care providers, great third sector organisations and humbling family carers doing an incredible job every day.

It deserves to be held as close to the nation’s heart as the NHS. It needs help and it needs a plan for the future. So, please tune in, encourage others to do so, and join the debate (on twitter if nowhere else #crisisincare) that we hope takes off when these programmes get aired.

Mark Ford
Communications Manager
Somerset County Council

Panorama Crisis in Care: ‘Who cares?’ and ‘Who pays’ are due for transmission on BBC One on Wednesday 29 May and Wednesday 5 June.

Posted on 21st May 2019

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Critically analyse the nurses' roles and responsibilities within care provision Introduction Nurses play an important role in providing care to patients in the NHS and often serve as the primary point of contact (Royal College of Nursing, 2018a). The Nursing and Midwifery Council’s (NMC, 2015) code of conduct has stressed the different roles of nurses, which include providing effective, high-quality, holistic and patient-centred care. Currently, nurses are faced with several challenges in the NHS, which included high turnover rates (Royal College of Nursing, 2018a). Despite these challenges, nurses continue to provide patient care while also fulfilling different leadership roles within the NHS. The main aim of this essay is to critically analyse the roles and responsibilities of nurses within care provision. Evidence from published literature, publications from the Department of Health, white papers and policies will be used to support the discussions in this essay. A conclusion then summarises the key points raised within this essay. Discussion Community Settings Registered nurses in the UK work in different healthcare settings. In communities, nurses are trained in providing patient-centred care in the patient’s own homes, health centres, clinics and residential accommodations such as care homes (Royal College of Nursing, 2018a). One of the roles of the nurses is providing basic care, which include checking the blood pressure, temperature and breathing of the patients (Royal College of Nursing, 2012). They also administer injections, assist GPs in medical procedures or examinations and are also responsible in cleaning and dressing wounds. They also monitor care of patients with long-term conditions and ensure that their different health and social care needs are met. Nurses in community settings often work in teams such as community district nursing teams (Royal College of Nursing, 2012). The roles of community nurses are important since these relieve busy GP surgeries and hospitals in the UK. Further, the NHS policy has made a shift in the delivery of care from hospitals to community settings (Newbold, 2013). It is suggested that this shift is most appropriate for patients with long-term conditions and is generally shown to be cost-effective and acceptable amongst patients (Newbold, 2013). However, a King’s Fund report (Ball et al., 2013) showed that in the last 15 years, the proportion of district nurses have not increased significantly. Instead, the number of district nurses has decreased by approximately 40% in the last decade (Ball et al., 2013). When a breakdown of community nurses was conducted, 25% had roles as district nurses while 49% were community staff nurses. Another 8% acted as community matrons while 11% were team leaders or case managers and 6% were specialist nurses. The same report argued that the reported quality of care is significantly associated with the number of patients that community nurses have seen. Those with higher caseloads reported poorer quality of care while those with lower caseloads stated that they were providing higher quality of care. Despite these observations, it is noteworthy that overall, more than half or 61% of the nurses in the King’s Fund report described their care in the last shift as ‘good’. Although the majority of nurses in community settings are satisfied with their jobs, they still report significant pressures. These included perceptions that their workload was too heavy and they were not receiving sufficient support from administration. It is important not only to recognise the roles of nurses but also to relieve them from excessive workloads that might negatively impact their roles. It has been shown that high workloads are associated with high nursing burnout, which eventually leads to leaving the nursing workforce (Bogaert et al., 2017). It is also important to note that nurses are responsible in collaborating care links between hospital staff, social care workers and other agencies (Maybin, Charles and Honeyman, 2016). This promotes continuity of care and ensures that patients with long-term conditions are receiving appropriate and timely care (Russell et al., 2011). However, the pressures placed on community nurses are straining current capacities of district nursing teams (Royal College of Nursing, 2012). The decline in the number of nurses in community settings and increased demand for services could lead to staff members being rushed and visits being postponed (Maybin, Charles and Honeyman, 2016). As a result, this would result in a lack of continuity of care and could negatively impact healthcare outcomes of the patients and the quality of care (Maybin, Charles and Honeyman, 2016). Hospital Settings Nurses in hospital settings serve patients from different age groups, cultural background, ethnicity and socio-economic status (Parand, 2014). These nurses are responsible for assessing patients prior to admission and for monitoring their care while they are admitted in the hospital. Nurses are also involved in creating discharge plans with patients and other members of the healthcare team and ensure that patients are referred to appropriate community specialists (Parand, 2014). Nurses are also responsible for promoting patient safety, high quality of care and in supporting healthcare decisions with evidence from published studies and guidelines (Royal College of Nursing, 2018b). During handovers, nurses have to ensure that complete information is conveyed to the next nurse on duty to avoid errors in medication that might compromise patient safety (Royal College of Nursing, 2018b). Similar to community nurses, nurses in hospital settings are also responsible in advocating in behalf of the patients. They are also involved in patient education and reassuring patients and their family members during patient care. Another important responsibility of nurses includes communicating effectively with the patients. Similar to problems faced by their colleagues in community settings, nurses in hospital settings are often understaffed (Royal College of Nursing, 2017). This is a cause for concern since in hospital settings, understaffing has been correlated with increased medication errors, which in turn compromises patient safety (Royal College of Nursing, 2017). Further, understaffing also increases nursing burnout and poor job satisfaction (NICE, 2014). It has been shown that poor job satisfaction could lead nurses to leave the nursing profession, which further exacerbates current working conditions in the NHS. In a survey carried out by the Royal College of Nursing (2017), results demonstrated that the right number of experienced and competent nurses is needed in order to protect the nursing profession and the public. It is argued that the right number of nursing workforce in the NHS is necessary in order to reduce mortality rates, improve patient outcomes and increase productivity (Royal College of Nursing, 2017). However, the continuous decline of registered nurses in the NHS could lead to life-threatening consequences since care is often left undone and would increase the risk of death (Aiken et al., 2014). Apart from providing direct patient care, nurses are expected to plan discharges, create care plans and document the care received by patients (Royal College of Nursing, 2018). They are also expected to do administrative work. However, this role could place an undue burden on nurses who are experiencing understaffing. For example, in a report commissioned by the Nursing Quality and Care Forum (Cunningham et al., 2012), results revealed that nurses have recognised the importance of paperwork in the nursing profession. Nurses who participated in the survey stated that paperwork is an essential part of delivering care and in communicating important information about their patients to other healthcare professionals. Further, nurses perceived that completing paper work would help in quality improvements and making healthcare services more effective for their patients. Nurses felt that it is their professional duty to provide information that would help improve healthcare services. However, the same group of nurses admitted that the amount and volume of paperwork that they are expected to complete makes it difficult for them to balance administrative work and patient care. Most importantly, the nurses reported that completing all required paper work reduces the time that should have been spent on personal, patient care. Cunningham et al. (2012) also reported that majority of the nurses or 77.9% found the task of completing paperwork as not only difficult but also time consuming while 68.1% of the nurses felt that paperwork added little value to the care of their own patients. Since nurses have the professional responsibility of providing quality, safe and effective care, many of the nurses also participate in audits. However, paperwork and data collection associated with these audits are time consuming and sources of on-going frustrations amongst nurses (Cunningham et al., 2012). With the burden associated with completing lengthy documents, nurses in the study recommended that duplication should be removed and documents simplified. Information technology is also seen as a viable tool in reducing the volume of paperwork that nurses are expected to complete during regular audits or patient care. Nurse Prescribing Nurses also have an additional role of prescribing medications within their area of specialty. However, only nurses who have trained and meet qualifications to be prescribers are allowed to prescribe medications (NMC, 2006). Specifically, the NMC (2006) has recommended standards of proficiency for nurse prescribers. These include assessing the patient’s clinical condition and undertaking a thorough medication history, diagnosis and use of complementary therapies or over-the-counter drugs (NMC, 2006). The standards of proficiency also include making decisions on whether it is necessary to prescribe medications and advising patients of the risks and effects of medications. The NMC (2006) emphasis that prescribing is only done if the patient provides consent or agrees to receive medications. Nurse prescribers are also responsible for monitoring response of patients to lifestyle advice and medication. The benefits of nurse prescribing within the NHS have been documented. Blanchflower, Greene and Thorp (2013) report that nurse prescribing has led to reductions in treatment delays. Patients also tend to report positive experiences with the prescribing process. In a survey conducted by Tinelli et al. (2015), patients reported that they had positive experiences and perceptions with their nurse prescribers. The patients also expressed that their nurse prescribers were able to build a positive rapport with them, which was necessary in helping them feel satisfied with the care they received. In addition, nurse prescribing has also been shown to promote autonomy, job satisfaction and patient outcomes (McBrien, 2015). Despite the positive outcomes linked with nurse prescribing, this important nursing role is still met with challenges. Both internal and external factors have been identified as limiting registered nurses to pursue the role of nurse prescriber. Internal factors included lack of motivation and apathy while external factors were related to logistic and busy schedules that prevented nurses to train as nurse prescribers (Tinelli et al., 2015). Conflict between professionals, particularly physicians who are at the top of the hierarchy, was another external factor that might hinder nurses from prescribing (Kroezen et al., 2012). Considering the potential benefits of nurse prescribing, it is necessary for nurse prescribers to receive support within their own teams (Tinelli et al., 2015). It may also be necessary to change attitudes and culture towards nurse prescribers in order to motivate more registered nurses to train as nurse prescribers. Conclusion The ultimate role and responsibility of the nurse is to provide quality, patient-centred care to patients in different health settings. In the community, this may mean collaborating with other healthcare professionals to ensure that continuity of care is practised and patients’ preferences toward their care are observed. In hospital settings, this may mean reducing the length of hospital stay through initiating timely and effective care. This would also mean collaborating with healthcare teams and the patients and family members to ensure patient-centred care. In both settings, nurses act as advocates to the patient in order to ensure their safety and increase patient outcomes and satisfaction. Nurses who have received specialist training and passed prescribing courses also take an additional role of prescribing medications to patients. However, these roles and responsibilities are often difficult to carry out with the fast turnover of nurses. The latter has been linked with poor patient outcomes, increased nursing burnout, which in turn results in more nurses leaving the profession. Amongst nurse prescribers, internal and external factors influence their roles and responsibilities as prescribers. Hence, there is a need to address factors that could have a negative impact on nursing care. Addressing these factors could help nurses in their most important role of providing safe, effective and high-quality, patient-centred care. References: Aiken, L., Sloane, D., Bruynee, L. Van den Keede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M., Moreno-Casbas, M., Rafferty, A., Schwendimann, R., Scott, P., Tishelman, C., van Achterberg, T. & Sermeus, W. (2014) ‘Nurse staffing and education and hospitality mortality in nine European countries: a retrospective observational study’, Lancet, 383(9931), pp. 1824-1830. Ball, J., Philippou, J., Pike, G. & Sethi, J. (2013) Survey of district and community nurses 2013: Report to the Royal College of Nursing. London: King’s Fund [Online]. Available at: https://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/DN-community-RCN-survey-report---UPDATED-27-05-14.pdf (Accessed: 14 February, 2018). Blanchflower, J., Greene, L. & Thorp, C. (2013) ‘Breaking through barriers to nurse prescribing’, Nursing Times, 109(31-32), pp. 12-13. Cunningham, L., Kennedy, J., Nwolisa, F., Callard, L. & Wike, C. (2012) Patients not paperwork- Bureaucracy affecting nurses in the NHS. London: NHS Institute for Innovation and Improvement. Kroezen, M., Francke, A., Groenewegen, P. & van Dijk, L. (2012) ‘Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a survey of forces, conditions and jurisdictional control’, International Journal of Nursing Studies, 49(8), pp. 1002-1012. Maybin, J., Charles, A. & Honeyman, M. (2016) Understanding quality in district nursing services: Learning from patients, carers and staff. London: King’s Fund [Online]. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/quality_district_nursing_aug_2016.pdf (Accessed: 14 February, 2018). McBrien, B. (2015) ‘Personal and professional challenges of nurse prescribing in Ireland’, British Journal of Nursing, 24(10). Doi: 10.12968/bjon.2015.24.10.524. National Institute for Health and Care Excellence (NICE) (2014) Safe staffing for nursing in adult inpatient wards in acute hospitals. London: NICE. Newbold, M. (2013) ‘Shifting care from hospitals to ‘Community’: A role for hospitals?’, British Journal of General Practice, 63(612), pp. 379-380. Nursing and Midwifery Council (NMC) (2006) Standards of proficiency for nurse and midwife prescribers. London: NMC [Online]. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-proficiency-nurse-and-midwife-prescribers.pdf (Accessed: 14 February, 2018). Parand, A., Dopson, S., Renz, A. & Vincent, C. (2014) ‘The role of hospital managers in quality and patient safety: a systematic review’, British Medical Journal Open, 4:e005055. Doi: 10.1136/bmjopen-2014-005055. Royal College of Nursing (2012) The community nursing workforce in England. London: Royal College of Nursing [Online]. Available at: https://www.rcn.org.uk/about-us/policy-briefings/pol-0912 (Accessed: 14 February, 2018). Royal College of Nursing (2017) Safe and effective staffing: Nursing against the odds. London: Royal College of Nursing. Royal College of Nursing (2018a) Education, prevention and the role of the nursing team [Online]. Available at: https://www.rcn.org.uk/clinical-topics/diabetes/education-prevention-and-the-role-of-the-nurse (Accessed: 14 February, 2018). Royal College of Nursing (2018b) patient safety and human factors [Online]. Available at: https://www.rcn.org.uk/clinical-topics/patient-safety-and-human-factors (Accessed: 15 February, 2018). Russell, D., Rosati, R., Rosenfeld, P. & Marren, J. (2011) ‘Continuity in home health care: is consistency in nursing personnel associated with better patient outcomes?’, Journal for Healthcare Quality, 33(6), pp. 33-39. Tinelli, M., Blenkinsopp, A., Latter, S., Smith, A. & Chapman, S. (2015) ‘Survey of patients’ experiences and perceptions of care provided by nurse and pharmacist independent prescribers in primary care’, Health Expectations, 18(5), pp. 1241-1255. Van Bogaert, P., Peremans, L., Van Heusden, D., Verspuy, M., Kureckova, V., Van de Cruys, Z. & Franck, E. (2017) ‘Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: A mixed method study’, BMC Nursing, 16(5). 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