Public perceptions of privacy and dignity in hospitals is research, conducted by Ipsos MORI, involved 2,000 interviews with members of the public across the country. It was designed to explore perceptions towards privacy and dignity in hospitals, with particular emphasis on the importance of single-sex accommodation. Key findings are that cleanliness and staff attitudes are the most important factors for patients to feel they are treated with privacy and dignity in hospital.

More than one in four adults admitted to hospitals, care homes or mental health units are suffering from malnutrition, the Nutrition Screening Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units has found. Women and the elderly were at greatest risk, says the report from the British Association for Parenteral and Enteral Nutrition (Bapen). More than 11,000 patients were screened for signs of being under-fed and 28 per cent were found to be malnourished.

It recommends:

• Screening should be undertaken in all institutions and repeated at interval according to care setting, using accurate and reliable instruments
• Results of screening should be included in care plans.
• Nutrition advice and nutrition support teams should be routinely available.
• Strategies to detect, prevent, and treat malnutrition should be in place in all care settings, including the community, where most malnutrition originates.

Patients will be able to choose where they are treated from any provider meeting Healthcare Commission standards from 1 April, but Free Choice at the Point of Referral a King’s Fund’s briefing on the latest official data finds the policy has some way to go before it is likely to drive improvements in the quality of hospital services.

One of the ambitions of free choice is to create incentives for hospitals to drive up quality standards as they compete for patients, but official data shows that:

• use of ‘Choose and Book’ — the computer system designed to facilitate choice — whilst increasing still falls short of the government’s target, with only 50 per cent of referrals from GP to hospital being made using the system
• although increasing numbers of patients say they remember being offered a choice of hospital by their GP since the policy began in 2006, the proportion is still only 45 per cent
• of those 45 per cent, only 27 per cent said their GP gave them a booklet containing comparative information on hospital performance to help them make a decision.

Trends in children and young people’s care - Emergency admission statistics 1996-2006 for children and young people aged 0 -19 years over the period 1996/97 to 2006/07,  including information on trends for:

• different age groups
• selected consultant specialties most likely to be involved in the care of children and young people
• emergency admission methods
• length of stay in hospital

Extensively discussed in the mass media Choice at referral: guidance framework for 2008/9  provides best practice guidance and information for referrers, providers and commissioners on how the roll-out of free choice in elective care in 2008/9 will operate.  It is supplemented by the Impact of Free Choice policy in Choose and Book R4.0.

Care provided by generalists at the end of life: scoping exercise on research priorities - Summary from the National Institute for Health Research considers the care that most people receive at the end of their lives from generalists  such as GPs, district nurses, hospital consultants and staff, nursing home staff and other health and social care professionals.

Key Findings:

• Generalist end of life care is care provided by many different practitioners who are not specialists in palliative care.

• The scope of generalist and specialist care is a matter for debate and variations in practice are evident. Definitions of ‘end of life’ care also vary, sometimes incorporating palliative care and sometimes referring just to the last few days of life.

• The limited research in this area has tended to describe existing services or needs, rather than to evaluate models of care or to examine health economic effects.

• Stakeholders are keen to see more research on models of care and place of care.

• Recommended priority areas for future research are:
  • defining and evaluating models of collaborative working in primary and secondary care
  • defining and evaluating models of out-of-hours provision
  • reviewing place of care and place of death for people dying from non-malignant disease
  • defining and evaluating models of care provided in different hospital settings.

• Research in each of these priority areas should include, in all settings, information on the:
  • patient and carer experience
  • resource and health economic effects and implications.

Three Final Reports have been produced.

• Report 1 - Overview and recommendations for future research in generalist end of life care,
• Report 2 - The literature scoping
• Report3 - The consultation report

Delivering Quality and Value: Consultant Clinical Activity 2005-06: Activity rates of consultants in five surgical and five medical specialties is a tool to enable acute trusts to benchmark consultant clinical activity in 10 specialties. Charts have been sent to individual trusts with the data for their own consultants. The methodology used this year is the same as previously and uses the methodology outlined in York University’s report: Measuring productivity of hospital consultants using hospital episode statistics in England (Executive Summary). This exercise will be repeated using HES data for 2006-07 and 2007-08.

Mental Health Act Commission Twelfth Biennial Report - Risk, Rights, Recovery finds that there are severe funding issues faced by providers of mental health services in that:

• Patients deemed to be a threat to themselves or others are being denied hospital beds while commissioners disagree with regard to funding.

• The Mental Health Act Commission has found practitioners are being told to delay sectioning people with urgent mental health needs until primary care trusts ascertain who should pay for their treatment.

• The problem is caused by high bed occupancy levels and the need for PCTs to balance budgets.

• This has encouraged PCTs not to detain patients who have travelled from other areas until the home PCT has agreed to pay.

Thse practices are unsuprisingly condemned in this report.

Report of the National Patient Choice Survey, England - September 2007 gives the final results of around 92,000 responses to the ninth national patient choice survey commissioned to assess the implementation of choice at PCT level. It monitors patient awareness of choice and recall of having been offered a choice of hospital for their first outpatient appointment.

Findings are:

• Marginal improvement in recall of patients being offered choice of hospital for their first outpatient appointment: 45% in September, up from 43% in July but still below 48% in the March 2007 survey.
• 39% of patients were aware of choice of hospitals for their first appointment, up from 38% in July and 29% in the May/June 2006 survey.
• 64% of patients who were aware of choice recalled being offered choice, whereas 32% of those not aware of choice recalled being offered it, compared with 63% and 32% respectively in the July survey.
• 79% of patients who were offered choice were satisfied with the process and 5% were dissatisfied.
• Location or transport considerations were given most often, by 65% of patients, as an important factor when choosing a hospital.

Mental Health Act Commission Eleventh Biennial Report (In Place Of Fear) questions whether all inpatient mental health services provide their patients with acceptable levels of security, care, or a sense of being treated as  someone who matters. It welcome the Government’s announced refocus on inpatient services and call for it to concentrate on building up these aspects, in place of the fear that many patients have of services and that many people have of mentally disordered people.  The importance of breaking such ‘circles of fear’ for Black and minority ethnic patients are particularly welcomed.

There is evidence that inpatient services are losing staff and resources to community
services, but that pressures on inpatient beds remain high. Over half of all wards are full or have more patients than beds, with staffing shortages and unpleasant ward environments undermining the therapeutic purpose of inpatient admission.

The report highlights the dangers inherent in devolved service commissioning for ensuring adequate levels of specialist provision, and note the vulnerability of mental health services as Trusts face financial crises.

The extension of patient ‘choice’ across health service provision should not be allowed further to disadvantage or ostracise patients who are unable to exercise choice because of their mental incapacity or because of legal powers of compulsion held over
their treatment.

Boundaries of current mental health law under stress, with discussion of about forty cases
in court, and a more general observation of legal powers being used in ways that may not have been intended by Parliament, often for pragmatic reasons where professionals are keen to intervene in what they perceive to be a person’s best interest or as measures of social order.

It also discusses aspects of the use of present mental health powers in relation to civil detention and police powers, including an extended discussion on the detention of mentally disordered offenders.We provide analysis of deaths of detained patients; seclusion incidents notified to the Commission; and Second Opinion activity during this period.

The report has a strong focus on measures to encourage and support the empowerment of all patients, including those without mental capacity to make certain decisions about their care.

It finally reviews the proposed future arrangements for monitoring detention of mentally disordered persons and suggest ways in which the forthcoming Mental Health Bill might be improved to ensure acceptability to mentally disordered persons and the effective protection of their rights.

Mental Health Act Commission Eleventh Biennial Report - Errata and Addendum

Summary of responses to the  ‘Options for the Future of Payment by Results: 2008/09 – 2010/11′ consultation put forward proposals for future developments in PbR including tariff setting, coding and classification, expanding the scope of PbR, and supporting health policies through financial reform.

This consultation sets out a single approach to considering whether and if so how, a chair or non-executive member of a Primary Care Trust (PCT), or a chair or non-executive director of an NHS trust, should be removed from office. The process may involve either seeking resignation or the termination of appointment and also introduces the potential use of a suspension function.

There is currently no legal framework for the Secretary of State to direct the Appointments Commission to suspend chairs and non-executive members or directors from office. The consultation documentation sets out proposals on the amendments that need to be made to the relevant legislation in order to allow for suspension of chairs and non-executive members or directors of PCTs and NHS trusts, and for temporary non-executive member(s) or director(s) to be appointed during the period of suspension. The consultation includes an impact assessment.

It is intended that the introduction of a suspension function for SHA chairs and non-executives will be covered by a separate consultation at a later date.

MRSA: Separating Fact from Fiction suggests the NHS could save millions if people with MRSA were sent home and not kept in hospital.

Home based treatment could also be better for the patient, said the report which was sponsored by the drug company Pfizer and produced by a panel of experts called the MRSA Separating Fact from Fiction Working Group in collaboration with the campaign group National Concern for Healthcare Infections.

The report said there is a need for an “integrated approach to the management, treatment and prevention of MRSA infection”.

Key to achieving this are clean hospitals, good infection control, and better information and treatment for patients.

The report calls for the following action:

• Give people accurate and user friendly information about MRSA and other HAIs.
• Tell people with MRSA about treatment options, including home treatment, if appropriate.
• Involve MRSA patients in treatment decisions.
• Consult the specialists, for instance microbiologists, about how to manage patients with MRSA and other HAIs.
• Hospital trusts should be ready to help MRSA patients be treated at home, if appropriate.
• MRSA patients treated at home should be supported and followed up and be given ongoing access to information and advice.

National Care of the Dying Audit generic report 2006/2007 considers the care of the dying in five key areas and finds that:

Physical Comfort of the Patient 

• Medication was assessed and non-essential medication was stopped in 93% of patients.

• Anticipatory prescribing was undertaken for pain relief in 91% of cases, for agitation in 84% of cases, for the prevention of respiratory tract secretions in 80% of cases, for nausea in 80% of cases and for breathlessness in 67% of cases.

• Inappropriate blood tests and antibiotics were discontinued in 87% and 91% respectively, and recording of ‘not for Cardio Pulmonary Resuscitation’ (where appropriate) documented in 93% of patients.

• In regard to ongoing care the presence or absence of symptoms could be recorded for patients during the last 24 hours of life. The status was not recorded for 18% - 19% of those assessments. Where the status was recorded patients were assessed as being symptom controlled in 95% for pain; 94% for agitation; 91% for respiratory tract secretions and 99% for nausea and vomiting of occasions.

Psychological and Spiritual Aspects of Care

On commencement of the LCP (Initial Assessment)

• Patient awareness of diagnosis and recognition of the dying phase was recorded as having been achieved in 57% and 45% of patients respectively. In one third of cases there was no documentation on the LCP suggesting a need for further education and training for healthcare staff.  Some hospitals, however, did achieve 100%.
• In over 80% of cases, carers were recorded as being aware of the diagnosis and dying phase, suggesting that healthcare staff find it easier to talk to carers
• The spiritual needs of patients and carers were recorded as being assessed in 34% and 53% (respectively) of appropriate cases

Communication with Patient,Carer and Healthcare Professionals

This is variable but carers were more likely to have had the care plan explained to them than the patient:

• At Initial Assessment, documentation confirmed that patients had the care plan communicated to them in over one third of cases, compared with 78% of carers.  It was recorded that 90% of those carers understood the care plan after it was explained to them.

• Communication with primary care (both on commencement of the LCP and after the death of the patient) was documented as having taken place in only about a third of cases, although there were pockets of good practice

Information Giving and Receiving

• Contact information about the most important person to contact in case the patient’s condition deteriorates was achieved at Initial Assessment in 79% of cases and Hospital information leaflets regarding facilities and access were given out in 59% of cases at that time
• Around the time of death or deteriorating condition of the patient (Initial Assessment), only half of families were recorded as having been given appropriate information about local and national procedures that may need to be followed.

Following Appropriate Procedures

• Following death, appropriate hospital procedures for laying out of bodies, storing of patient’s belongings and other activities were documented as having been followed in around half of cases.  However, the high level of care after death goals that are left blank at the point of delivery of care requires more investigation before firm conclusions can be made. 

Hospital organisation, specialty mix and MRSA presents an analysis of the contribution of organisational factors, such as bed occupancy rates, cleanliness and use of temporary staffing; to understand the variations in MRSA rates between different hospitals. The paper also examines how these relationships may have changed over time.

The NHS has improved dramatically over the last few years, but still cannot guarantee that basic minimum standards are being met for patients throughout England and Wales, according to State of Heatlhcare 2007: Improvements and challenges in services in England and Wales. More than a quarter of NHS hospitals failed to provide adequate emergency services for children and 48% could not provide children with a satisfactory service in outpatient clinics, the Healthcare Commission said in its annual report on the state of the nation’s healthcare.

Key findings are:

The health of the population is improving with significant increases in life expectancy, but there are major disparities around the country, particularly in poorer areas where there are often fewer GPs.

• Men are living over four years longer than they were 20 years ago, while women are living three years longer.
• Men from more deprived areas live for a decade less than those in wealthier areas. Looking at local authority areas, for example, Kensington and Chelsea has the highest life expectancy for both men and women, at 82.2 years and 86.2 years respectively. The lowest life expectancy for men is in Manchester at 72.5 years, and for women in Liverpool at 78.1 years.
• In poorer areas, where people tend to experience worse health, there are 18% fewer GPs than in the least deprived areas (54 per 100,000 people compared to 66).

Patients are positive about hospital services overall but some organisations perform poorly. Beneath the headline figures there are concerns about aspects of care such as dignity and privacy.

• National analysis of the Commission’s survey of 80,000 inpatients at acute hospital trusts shows that 89.2% (149) were ranked “satisfactory” on patient experience, 7.8% (13) were “below average” and 3% (5) were “poor”. Eleven of those in the latter two groups were rated as “below average” or “poor” for the second year running. The survey also shows concern about specific issues such as help with eating - one in five patients who wanted help eating did not get it.
• Almost a third of the complaints about hospitals referred to the Commission for independent review relate to dignity and respect, nutrition and other aspects of basic personal care. They included: patients left in soiled bedding and clothing; no regular baths or showers or oral hygiene; inappropriate or inadequate clothing.

There have been dramatic improvements in waiting times but there are hidden waits for some services, which are not measured and therefore difficult to address.

• Government standards say no patient should wait longer than 26 weeks for a hospital appointment. In 2006/07, 83% of trusts met this, leaving some 350 patients with longer to wait than 26 weeks. This is a vast improvement on figures for 2000 when 264,000 patients waited this long.
• Waiting time targets do not apply fully to some services, making it difficult for problems to be addressed and patients needs to be met. Evidence suggests that a two-year wait for those referred for psychological therapies is not uncommon. People in some areas are still waiting between 12 and 24 months to have hearing aids fitted.

NHS trusts are performing better overall on quality of services, but the performance of primary care trusts (PCTs) has declined, with many not getting to grips with the needs of their communities so as to provide services to match.

• Overall, the quality of NHS services is improving with 46% of trusts rated ‘excellent’ or ‘good’ in 2006/07, compared to 40% in 2005/6. But for PCTS, only 26% were ‘excellent’ or ‘good’ in 2006/7 compared to 33% in 2005/6. Many PCTs went through a reorganisation over the period but this does not provide a complete explanation for the underperformance.
• The Commission says PCTs form the bedrock of healthcare. They control more than three-quarters of the budget, purchasing services from other providers, including hospitals. They are directly responsible for providing services handling more than 80% of NHS contact with patients, including those carried out by GPs and dentists.
• The report says that many PCTs do not fully understand the health needs of their local people, making it difficult for them to buy targeted services. For instance, last year 2.3 million people did not have their BMI index recorded as planned, with GPs not recording the data, which provides vital statistics on levels of obesity. The number of people diagnosed with heart failure is also considerably less (140,000) than expected, indicating that GPs may not be picking up on signs of serious illness. There is also a poor understanding of the sexual health of local populations at a time when sexually transmitted infections are rising rapidly.
• Where there is a known need, PCTs are not always providing the services required. Some 60,000 people with serious long-term conditions did not get the care from community matrons that was originally planned. Forty-one per cent of PCTs failed to purchase sufficient crisis services for people who are seriously mentally ill, resulting in 5,000 fewer people receiving the service than planned. Some 85% of PCTs did not have arrangements for providing education programmes for patients with diabetes in their area. And 2,000 GP practices did not fulfil their PCT’s plans to establish registers for those people at risk of coronary heart disease, designed to help prevent these patients from becoming seriously ill.

There is progress towards a stronger culture of safety and grounds for cautious optimism in reducing healthcare-associated infection. But trust boards need to show stronger leadership.

• On safety more generally, there has been an encouraging increase in reporting of incidents. Reported figures show more than 229,000 known incidents causing low or moderate harm and more than 9,400 incidents causing severe harm or death.
• Only 58% of NHS trusts complied with all the government’s nine core standards on safety, with infection control, decontamination of medical devices and medicines management the biggest areas of concern.
• Infection control is arguably of greatest public concern; latest figures suggest grounds for cautious optimism. Cases of MRSA fell from 7,096 in 2005/2006 to 6,381 in 2006/2007. There are early signs that increases in cases of Clostridium difficile are slowing. Between 2005 and 2006 the number of cases increased 7% to 55,620, compared to a 16% rise from 2004 to 2005.
• By the end of October 2007 the Commission had visited 87 trusts to check their performance in meeting the requirements of the hygiene code. Only one trust needed to be issued with an improvement notice, suggesting that organisations are taking the issue seriously. But there was a need for stronger leadership from trusts’ boards to improve monitoring, isolation facilities, training, and compliance with policies and procedures.

New figures show that more independent healthcare providers meet core standards, mirroring a similar trend among NHS trusts. But there are concerns about compliance among independent providers of mental healthcare.

• The proportion of independent healthcare establishments that met the government’s national minimum standards - including those that were not inspected as they were considered not to be at risk - was 63% in 2006/07 compared to 50% the year before. Five per cent of independent establishments failed five or more of the standards.
• Although NHS trusts must meet a different set of standards, the broad picture is similar. The number of trusts that were “fully met” on government core standards rose from 49% in 2005/06 to 55% in 2006/07. Six per cent of trusts were judged “not met” on core standards overall.
• In the independent sector, non-compliance was greatest on national minimum standards covering: monitoring of quality of treatment (C4); ensuring patients get care from appropriately recruited, trained and qualified staff (C9); and taking account of patients’ views (C6).
• Independent mental health providers, which mostly look after NHS patients, performed worse than others in the sector. Non-compliance was greatest in relation to national minimum standards for: ensuring patients receive care from appropriately recruited, trained and qualified staff (C9); providing treatment in safe and appropriate premises (C17); and ensuring patients are resuscitated appropriately (C27).
  Independent providers of mental health services need to focus on ensuring patients are appropriately and safely restrained. In 2006/7, 17% of establishments failed a standard in this area compared with under 9% in 2005/2006.

The NHS often fails to meet the needs of children and young people and there are concerns about other groups requiring specialist care, such as people with mental health problems and with learning difficulties.

• Paediatric hospital services are generally good at looking after children, but other more general services are not. Some 70% of specialist inpatient services were rated “good” or “excellent” by the Commission, but 28% of emergency and day case services were “weak”. Transition from children to adult services is not managed well in services for people with mental health problems, diabetes and disabilities, and those requiring palliative care services. Vulnerable children such as those with disabilities, those in care and young offenders face particular problems in getting appropriate care. One in 20 NHS trusts are not yet compliant with child protection standards.
• On specialist wards for people with mental health problems and people with learning difficulties, more than half of the inpatients were found to be in mixed-sex accommodation.
  Levels of violence in mental health services remain high, although there are signs of it being dealt with better. The report includes new data from an audit into violence in the sector, which found that almost one in 20 patients reported being assaulted. Forty-six per cent of nurses reported being physically assaulted, and 72% said they had been threatened or made to feel unsafe. On older people’s mental health wards, almost two-thirds of nurses reported physical assault by patients.

There have been dramatic improvements in responding to the big killers - cancer, circulatory and respiratory disease - but five-year survival rates for cancer, and mortality rates for respiratory disease, are worse than in other comparable countries.

• The mortality rate for people under 75 diagnosed with cancer fell by almost 17% between 1996 and 2005, which suggests that some 60,000 fewer people died prematurely.
• Despite this improvement, the UK survival rates do not compare favourably with most of Europe. For instance, the survival rate for lung cancer in Holland and Spain is around double that in England, which stands at 6.5% for men and 7.6% of women.

Pandemic influenza: guidance for infection control in hospitals and primary care settings replaces the infection control guidance published in October 2005. The changes and amendments in this edition are detailed on page 4 and include updated advice on aerosol- generating procedures. This advice takes into consideration and addresses the categorisation of such procedures in the recently published interim guidance from the World Health Organization on ‘Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care’.

Draft guidance has been issued by the Department of Health to support planning for any incidence of pandemic influenza.

Pandemic flu: A national framework for responding to an influenza pandemic describes the Government’s strategic approach for responding to an influenza pandemic published jointly by the Department of Health and the Cabinet Office. It provides background information and guidance to public and private organisations developing response plans. It updates and expands upon health advice and information contained in previous plans issued by UK health departments and is intended to replace those documents.

Planning

Responding to pandemic influenza – The ethical framework for policy is designed to assist planners and strategic policy makers with ethical aspects of decisions they face before, during and after an influenza pandemic. It may also help clinicians and other health and social care professionals with decisions they need to make in the same context.

Pandemic influenza: surge capacity and prioritisation in health services - provisional UK guidance gives guidance on managing the surge capacity needed to respond to an increased volume of patients during an influenza pandemic.

Pandemic influenza: human resources guidance for the NHS is designed to give an overall framework for local organisations to build on/work within and deals in more detail with the workforce and human resource issues that may arise in the pandemic.

Pandemic influenza: Guidance on the management of death certification and cremation certification proposes changes to the procedures for death and cremation certification that could be used in a severe influenza pandemic in order to enable doctors to spend as much time as possible on the care of the living and to ensure that processes for death and cremation certification can be managed as effectively as possible during a pandemic

Service Based Guidance

Primary care guidance will assist primary care trusts (PCTs) in developing their plans for responding to an influenza pandemic. It is also intended to be a useful document for primary care professionals such as those working in general practice, community pharmacy and nursing, and for partner agencies providing services in the community setting. Also relating to the Primary Care setting is An operational and strategic framework: planning for pandemic influenza in adult social care which is supplementary to the revised national framework for responding to an influenza pandemic. It is intended to help local authorities, providers of social care services and PCT’s plan ahead for how they will manage and respond to the situation.

Pandemic influenza: Guidance for ambulance services and their staff in England provides ambulance trusts with a clear and pragmatic guidance to assist with their planning and reparations for an influenza pandemic. Specifically, it advises on national strategy, clinical management (including infection control) and business continuity planning.

Pandemic influenza: Guidance on preparing acute hospitals in England is designed to assist acute hospitals and foundation trusts in England in developing their plans for responding to an influenza pandemic.

Pandemic influenza: guidance on preparing mental health services in England is designed to assist mental health trusts and other specialist mental health service providers in developing their plans for responding to an influenza pandemic. This document details a national approach, setting out the key planning assumptions and principles, roles and responsibilities that should inform the development of local plans.

The Commissioner 2(11) (link to this months contents) has just been published. You can sign up for the e-mail alert on its blog, contact Katherine Bell its editor to get a mail of the pdf version or just subscribe to its RSS feed using the icon below.

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This month’s contents are:

• Diabetes in the NHS: Commissioning and providing specialist services
• NHS Stop Smoking Services
• Commissioning for Patient Pathways
• Commissioning specialist adult learning disability health services
• Care Outside Hospital
• Delivering the 18 week patient pathway
• Eye care
• Commissioning Roadmap
• Facing the Future
• Report of the High Level Group (HLG) on Clinical Effectiveness
• Other documents

The Healthcare Commission is calling for NHS trusts to do more to ensure they consistently provide dignity in care to older people, including offering adequate nutrition and privacy. They have published Caring for dignity: A national report on dignity in care for older people while in hospital  a national report on dignity in care. It warns NHS trusts of further checks, including unannounced visits, where there are clusters of evidence suggesting a problem at a hospital or on a ward. It is asking patients, their carers and the public - and their representative bodies like Age Concern - to come forward and tell the Commission where they have reason for concern.