Private healthcare versus Statutory copyright Carol Dimon 2013

There are 20000 nursing students in the UK ( Campbell 2013) , fees paid for by the government unless student is from overseas. Education content to be addressed is identified by the NMC (2010 ) but modules are determined by the University. Of those 20000 students, many may not practice as nurses at all, many may leave nurse training(Kendall-Raynor 2012 ), some may go abroad and many may work in the private healthcare sector. There are no available national figures for this. Whilst care homes must be referred to according to the NMC, how prepared are student nurses to practice in the private sector? Is there indeed a difference? It is further indicated with the establishment of Foundation Hospitals that there may well be a greater increase in the private sector. Indeed, private beds are presently used by the NHS for patients who cannot be accommodated elsewhere. Foundation Trust hospitals do appear to mirror school academies which the Government do propose to privatise (Merrick 2013). One wonders why the increase in privatisation? It may well be that the Government therefore abdicates responsibility for standards within them as reflected by the existence different policies and procedures .

This article will explore some of the major differences between the two sectors, focussing largely on care homes and NHS hospitals.

You may all say CQC standards are the same. But different issues arise within care homes to hospitals. It must be noted also that the CQC Registration Regulations (2009) also apply which refers to such aspects as notification of death and statement of purpose of the registered premises . Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 also apply (CQC).

The manager of a care home is the registered manager according to CQC and the 2009 regulations. In a residential home this may be senior care assistant. In a nursing home it is a registered nurse. This means he or she is responsible for everything from light bulbs to staff levels ( Dimon 2005 ). Indeed there are cases of home managers jailed for low staff levels that resulted in poor resident care (Bunyan 2012). Speaking of the home manager, in large company, the judge declared “ As the home manager, you were responsible for the care and well being of residents” (Bunyan 2012). Consider this. The running of the home also depends upon who or which body owns it. What can the manager do when he or she is forbidden to ring agency? (Dimon 2005). Here the manager is torn between budget and quality of care. Indeed, it may well be that nobody is available via the agency. Reporting staffing levels in the private sector differs to an NHS hospital.

The registered manager of an NHS hospital is the chief executive or equivalent; who is not necessarily a qualified nurse or doctor.

In an NHS hospital- the nurse in charge informs the ward manager. The ward manager contacts other wards. Informs higher manager if the problem keeps re-occurring. Does the book stop there? There is higher- the CQC if need be.

In a care home the manager may ring the owner if individual owned. Then the CQC if no satisfaction. If company owned- ring the regional manager and go higher and ultimately inform the CQC inspector each time they are short of staff. Easy isn’t it? I will not discuss whistleblowing here and possible repercussions.

What of other differences? All hospital care assistants receive planned training , the content did vary between them but now in all care establishments, must be based on Skills for Care Core elements. Yet variations may continue to occur since no duration is specified for the training, no exact content, and assessment is done in –house. There are a vast number of influencing factors here. Who will provide the training? What will it consist of? How long will it be? Will staff be given time to attend?

Regarding regulations ;The Health and safety Act 1974 applies to all establishments regarding education and records for example. Home managers need to be aware how to inform appropriate agencies concerning RIDDOR; unlike hospital, they may have nobody else to refer to. Yet separate issues may arise within care homes. The HSE website offers a free downloadable booklet regarding specific issues and guidance for care homes. Whilst it is a 2001 publication, it is still of relevance. When in hospital does a nurse have to be aware of electrical and gas regulations? When do nurses in hospital have the responsibility of ensuring that all items are PAT tested? When does a ward manager have to ensure that equipment such as lifts are checked every year and maintained? When is there a stairlift in a hospital? Hence the differences.

Food and hygiene. The European Community Food Hygiene Regulations (2006) replaced the Food Safety (General Food Hygiene ) regulations 1995 (westberks). Care homes must be registered as food business with the local authority Environments Health Department. There is separate guidance for care homes since so many different issues apply such as residents who wish to have relatives bringing food in for them (HPA 2013). Anecdotal evidence and a study (2010) indicates that many care home staff and managers are unaware of legislation governing infection control; how many care home managers are aware to inform environmental health if they have 2 or more outbreaks of vomiting and diarrhoea? All staff in a care home need to be aware of this requirement. It is against regulations to wait from Saturday until Monday to do anything. Not all are aware that the environmental health is on call for this purpose and can be contacted via the accident and emergency dept of the local hospital if you do not have the emergency number. Also education or resources may be lacking; some respondents in one study (HPA 2010) washed bedpans in communal baths or residents’ sinks. HPA (2013) also detail advice regarding waste control, uniforms which are not required to be removed when leaving work but recommended and such infections as scabies which do arise in care homes. Regarding responsibility, the HPA does state clearly, that the person in charge within a care home, is responsible for such as waste removal for which they recommend an audit. Hence the difference regarding hospitals .

Staff who serve and prepare food need appropriate training. In a care home, this may mean all care staff as there is not always anybody in the kitchen. Staff in hospital- do not even usually enter the kitchen.

Hence whilst the same regulation applies, individual situations and establishments, must be considered.

Pharmacy regulations also apply, in addition the NMC medicine guidelines (2008) if you are a registered nurse. Yet there are different issues in care homes.

Often doctors may ring and change the dose of a medication over the phone. What does the nurse do then? It is recommended that you insist upon a fax or other means of written information (NMC 2008). In care homes, staff may not always have access to a fax or computer however, out of hours.

In care homes oxygen may only be kept when it is prescribed for a specified patient. You can however, buy the oxygen or rent it which means you have to contact an oxygen supplier (NICE 2010, Mr McGill). Even then, not all staff are aware how to use it. In hospital, there is a wider team of staff to draw on.

Homely remedies. There are no specific regulations here apart from what actually may be given at all without a prescription of course (Mr McGill) but there will be local policies. How many staff are aware that to give homely remedies in care homes a home remedy protocol (NMC 2008) must be agreed according to the GP of those residents, the pharmacist and the care home inspector. Different GPs will allow different medications to be given unprescribed. This also applies to creams and simple dressings. In hospital, there is already an agreed protocol and policy within that hospital. Further dressings may only be given to the resident for which it is prescribed. Same applies to medication.

Disposing of unwanted medication is also an issue. This depends on agreements with local funding bodies . Residential homes unwanted medications are removed by their pharmacist. In nursing homes the nursing home owner must pay a company to remove them (Mr McGill). So despite regulations such as the Medicines Act 2012 being the same, their implementation differs.

Obtaining medication in emergencies may well be a problem in care homes. Is there enough staff to enable one to go and does he or she have a car?? If nurses are not taught this and especially overseas nurses, how can they be held responsible? Yet every care home differs according to who owns it. They all have different policies.

Maintaining finances of residents. In hospital do not usually maintain bank books yourself. This would be done by hospital admin. Does however again, depend who owns the care home. Some home managers have had to establish bank accounts themselves on behalf of residents.

All residents within care homes have a right to receive all aspects of healthcare. Yet there are indications and is anecdotal evidence, of difficulties obtaining GPs or physiotherapists for example (BBCnews 2012). Some homes do actually employ specific professionals themselves. GPs may be reluctant to visit for example, yet there are dilemmas regarding how to transport the resident to the GP practice.

This may well be the future of hospitals. Foundation hospitals instil a business-like approach, Managers are thus able to opt to use private services such as Boots the pharmacist. It may also mean that hospitals establish their own policies hence they too, become different to one another. If we are marching towards privatisation, we need to be prepared.

How many are aware of Deprivation of Liberty Safeguards? Indeed, CQC recently found there was a neglect to apply these safeguards and failure of some care home companies to educate staff regarding this (Samuel 2012 ), hence restraint was being used such as bed rails without obtaining permission , and locking patients in their rooms on occasion. There are issues for night staff when this safeguard must be applied but there is no emergency contact for the procedure apart from the manager who cannot grant permission normally . Again large companies do generally update and inform their staff . Yet problems still occur within them .

What of the complaints procedure? Within the private sector this is actually weaker. NHS hospitals have PALS and if they are foundation trusts which they all soon will be , they also have Monitor. Private establishments do not have this, yet they do have complaints procedures. If it is a private hospital the Independent Healthcare Advisory service will advise patients about complaints, if the hospital is a member. If it is a care home and it is owned by one person, you complain to the home manager or owner. All have a right to ask a patient to leave the care home with one months notice, if they cannot meet their needs in whatever way. There is evidence of this having occurred (alzheimers) and in some cases, alternative reasons for informing the resident to leave may well be provided such as, “we cannot meet your needs”. This may well be the case in some situations but not others. It is a business after all. Where can you go in a restaurant if you do not like the service?? Personally- I just opt to go elsewhere but not always an option in healthcare. Companies have regional managers and board of directors. Homes may also be owned by charity bodies which many are reluctant to complain to or about or indeed, the NHS owns some care homes. Regarding Charity bodies, the Charity commission will only consider extreme issues.

The complaints procedure for residents and relatives in care homes, does depend on how the resident’s care is funded ; by themselves or Local authority or NHS. (Dimon 2014)

So what of support for staff? There are actually many staff who wish to raise issues. Anecdotal evidence informs us that within some areas of the private sector, individuals especially overseas staff or care assistants, are discouraged from joining a Union. ACAS does exist however, to offer free independent advice and mediation regarding employment issues.

Regulations regarding staff differ in application between private and statutory establishments. Indeed, some private establishments have clearer policies and procedures than others concerning disciplinaries for example.

So what about care? How can different issues arise there?

Examples remain of getting all residents out of bed at 4am against their wishes( Ford Rojas 2011 ) due to short staff and pressure from the opposite shift. Hence Human Rights consideration is essential within this vulnerable area of care. Or is it just common sense?

Consider a patient with extreme diarrhoea; Clostridium Difficile who needs barrier nursing. He is so confused he removes his incontinence pad and wanders about. Can happen in hospital possibly longterm care, more likely in a care home due to the nature of the resident. In either place, there may not be enough staff to enable one person to sit with him all day. It is illegal and inhumane, to lock him in his room . Resources such as available bins and appropriate sinks may differ, even carpets are an issue. In some care homes, cleaning resources may be inaccessible when the domestic has returned home.

Whilst Government action concerning the Francis report (2013) has yet to be determined, these recommendations will not necessarily apply to care homes or indeed, the private sector, unless the Government decide otherwise.

Whilst this article may appear to be critical of the system, it is merely meant to inform people of the differences in practice concerning actual regulatory requirements and the implementation of regulations . For this, we need to prepare nurses which is essential within nurse education. Yet how can students be prepared when the majority of lecturers, have never worked within a variety of private establishments, owned by different bodies? Many students leave education because they are unhappy with situations they are finding. They need open and honest discussions concerning actual dilemmas of practice.



Human Rights Issues Arising From The Treatment of Old Persons in Hospital and Residential Care


BBC news (2012)

Care Home Residents Lack NHS Services- CQC Survey 7.3

Bunyan N (2012)

BUPA Put Profit First and Filthy at Understaffed Care Home, says Judge

The Telegraph 17.3

Campbell D (2013)

Nurses Must Spend a Year on Basic Care

The Guardian 26.3

Dimon C (2005)

The Challenging Role of The Care Home Manager Nursing and Residential Care

December. V 7 n12 p571

Ford Rojas JP (2011)

Residents At Short-Staffed Care Homes “Woken At 4am”

The Telegraph 11.1

HPA (2010)

A Report On The Management of Diarrhoea in Care Homes

HPA (2013)

Prevention and Control Of Infection In Care Homes- An Information Resource

Dept of Health

HSE (2001)

Health and Safety in Care Homes

Health and Safety Executive

Kendall-Raynor P (2011)

Nationwide Initiative To Reduce Student Dropout Rates Revealed

Nursing Standard p14 Sept 21 v20n3

Merrick j (2013)

Secret Memo Shows Michael Gove’s Plan for Privatisation Of Academies

The Independent 10.2

Mr J Mcgill

McGill’s pharmacy

Ross T (2013)

Care Home Staff to Have Compulsory Training Under Government Plans To Protect The elderly

The Telegraph 8.3

Samuel M (2012)

CQC:Care Homes Failing To Train Staff in Deprivation of liberty 27.3




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