Boundaries . . . by @AnneMar43403619

“Freedom brings men rudely and directly face to face with their own personal responsibility for their own free actions. (Frank Meyr, 1962 in Defence of Freedom).

Anne 1Do you ever get the feeling that the NHS is trying to run a five star service on a one star budget? Quite some time ago a motivation speaker came to talk to many of the senior managers within D&G NHS about the indisputable fact that demands on the NHS would continue to increase and resources would continue to decrease proportionately.  He asked them to think out of the box about how we could start to overcome this increasing discrepancy. So, here’s some thoughts…

 It is almost as though the welfare state (indisputably needed and a mark of a civilised and moral society) has created its own Catch 22 with so many people believing their right to a choice, their choice, is paramount regardless of the impact on anyone else either individually or corporately.

 This fundamental change in people’s expectations comes with an increasingly litigious mentality and is leading not only the NHS but all welfare provision to breaking point. The boundaries of personal and social responsibility seem to be getting dangerously blurred and I believe that it is time to start defining healthy and sustainable boundaries again. To start saying, dare I say it, ‘No’.

 Before you all shoot me down in flames please be aware that I am not decrying the drive to improve patient care or the patient experience – we all want the best treatment and care for our patients, but it has to be within reasonable and sustainable limits.

 It seems to me, and a lot of my colleagues that it should be possible to cut back without affecting front line services – but the cuts would affect at least two forbidden areas: the patient experience and those strategists who think that forty page documents talking about interface working and cross sectional content mean or change anything.

The latter is probably best summed up by a quote from an anonymous but very well known NHS source: “As is well reported the management and administrators within the health service could keep themselves busy in an empty hospital with paper exercises.”

 Maybe we could summarise the government’s strategic direction 2020LDP paper thus: “Continue to work together to provide the best patient care across all services within budget constraints.”  One person, two minutes, cost to the NHS about 20pence.

O.K tongue in cheek but you get my point.

Anne2Any measures that negatively affect the patient experience would be controversial but when you look at it in terms of managing your own home and how your budget affects the choices you make and are sometimes forced to make surely it becomes simpler. Running your own home involves setting limits and boundaries, it involves denial, taking second and third best or frequently going without at all and it is not just you, the adults, but your children that are affected by the choices you make. If you teach your children and help them understand why they cannot always have just what they want when they want they learn to value your family resources, understand why sometimes the answer is ‘No’,  maximise family resources and then take on their own responsibilities as they grow up.

 Perhaps it is time for the NHS to set some realistic boundaries of its own and make it clear that it simply cannot meet every demand or expectation, public or otherwise. Can we really expect to be able to continue paying for patients to occupy acute beds simply because they don’t want to go to a community hospital? Or let patient choice costs tens of thousands of unnecessary pounds when there is an alternative that costs so much less? Can we expect to continue to fund hundreds of unnecessary visits to A&E or GPs, to shell out blanket free prescriptions? Or, on the other hand, continue to allow employees to stick to procedures that not only cost more but have a negative impact on a patients physical, mental and social well-being – just because they have always done it that way? Or to recall patients repeatedly for hospital check ups when a telephone call would do? Or to take up an acute bed simply because a patient needs an urgent scan but is otherwise well. Or to …. the list is endless.

 Why is it so difficult for people to set sensible and realistic boundaries and stick to them? Why do we, as staff, so often capitulate to our patients every whim: “Not eating that sandwich I want grated cheese not slices!” and with each capitulation re-establish the boundary even further in the patient’s favour.

 How too is providing for every expressed patient need going to encourage the culture of self management that is being flagged up as an essential part of the NHS future? Granted there are a huge number of things that are crucial to improving the patient experience that should be a fundamental part of the treatment they receive anywhere in the NHS – respect, courtesy, clear information, empathy and openness – but maybe we need to remember that the original ethos of the NHS was treatment free at the point of delivery based on clinical need.

Clinical  need – not desire.

Anne Marshall is a Staff Nurse on the Renal Unit at NHS Dumfries and Galloway

 

24 thoughts on “Boundaries . . . by @AnneMar43403619

  1. I could not agree more with the extremely pragmatic nature of this piece. Allowing patients to always have the absolute right to what they want, rather than what they need, would be unsustainable even if we had Germany’s economy. Spiralling costs based on a population who expect the NHS to take care of every single aspect of their physical and emotional wellbeing will bring it to it’s knees, at which point it will be killed off by the politicians. We really do need to start saying no, and telling people that some of their problems are their own, not ours, and not the State’s.

  2. thought provoking and i hope will make “the powers that be” sit up and take notice.
    Every year we are challanged with cost cutting to the point that the only realistice ways to cut expenditure is “Staffing”, but there is a no redundancy policy (of which i am glad).
    We need to wake up and smell the roses our our garden will wither and die as we wont be able to “manage” it

    • I hope it will too – but I do realise that the issue is a great deal more complicated than a few hundreds words in a blog!

  3. So true ! Made me smile on a Friday morning,couldn’t have said it better …Rarely have time to read these blogs far less respond but I’m glad i caught this one…wonder how many managers have the time???

  4. Whilst I understand the sentiment of the piece, I can’t help wonder why focus on saying ‘No’ to the patient, why is the spotlight on them? They are only expecting what they have been told they will get – but by who? The NHS? Politicians? or society as a whole? So who should we really be saying no to?

    • “If you teach your children and help them understand why they cannot always have just what they want when they want, they learn to value your family resources, understand why sometimes the answer is ‘No’, maximize family resources and then take on their own responsibilities as they grow up.”
      Similarly, if you ask your children where they would like to go on holiday, they may say “Disneyland, for a fortnight!”. Do not be surprised if they are upset and disappointed if you planned all along to take them to the Lake District for a long camping weekend.
      Perhaps it is time to rethink how we engage with the public. It is right that the NHS should seek some form of engagement with the public, but the current model (‘patient empowerment’, ‘user involvement’) creates a sense of power without accountability. Which patient group would not campaign for the introduction of a costly intervention of limited benefit – provided that someone else is footing the bill?

      • Thanks for your very thoughtful response. I agree with you but unfortunately the limitations of a blog restrict me from expanding what is an incredibly complex series of arguments.

    • You are right but unfortunately the blog format does not give me enought words to thoroughly argue a case. However I do not believe that patients are only expecting what they have been told they will get – it appears to me, and I could be wrong, that there is a fundamental difference in what people expect depending on their age and life experience. There are no easy answers!

    • You are right but unfortunately the blog format does not give me enought words to thoroughly argue a case. However I do not believe that patients are only expecting what they have been told they will get – it appears to me, and I could be wrong, that there is a fundamental difference in what people expect depending on their age and life experience. There are no easy answers!

  5. i often read these and have never responded however this really pushed my buttons ! i couldnt agree more with this blog and sincerely hope those higher up the chain take the time to read it. the demands of staff to provide more with less are pushing us to breaking point. i worked in australia in a detox clinic where people were prepared to travel over 2000 miles to access the right treatment, yet i have had people asking for home visits who live within 5 miles of my clinic because they dont drive. im not saying for one minute we should be making people travel 2000 miles to see us but the reality is i can see far more people and provide a much more cost effective service if people are prepared to travel to me. that in turn should make for a better patient experience for more people.

  6. Good point , well put. I agree , as many others on the ” inside ” will . Clear and sensible boundaries will enable person-centred care to be delivered In a more realistic environment .

  7. As a newly qualified nurse I also couldn’t agree more. I am shocked at the demands on staff and strongly feel that ‘the NHS is trying to run a five star service on a one star budget’. I believe this is having a huge negative impact on patients and staff alike. I certainly don’t feel I have the answers but I hope there will be changes ahead.

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  10. Of course, the WHO considers that the NHS is one of the most cost effective health organisations internationally, possibly partly BECAUSE we aspire to run a 5 star service on a careful budget.
    I think we beat ourselves up sometimes, but overall, despite the overwhelming size of the service, like many other religions, the people involved whether patients or staff, generally seem to tow the line. I for one, am happy to keep offering a nicer sandwich to the elderly lady on my ward who struggles to get the cardboard offering down.

    • The whole point of the blog was to start a healthy debate and hopefully instigate change that would help the NHS run more effective and efficient services. I am not sure how a budget can be carefull and I am not sure that many people would use the word religion to apply to the NHS let alone in the same breath as ‘tow the line’. You seem to believe that towing the line is a positive whereas I would argue that informed questioning and challenging is essential to a healthy service and workplace. You seem to have missed the point of the blog – it was never about denying an elderly patient ‘a nicer sandiwch instead of the cardboard offering but about setting healthy boundaries to ensure the best and most effective use of scarce resources for the maximum number of patients.

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