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New inspections will target conditions for the elderly, writes Stephen Naysmith
The question would seem strange to most members of the public – surely it is obvious? But Dr Denise Coia, chair of Health Improvement Scotland (HIS), insists it is not so simple.
"That's difficult for an inspection to measure," she says, agreeing when I suggest there is a subjective element to it. "One way we are doing it is to involve members of the public, and just spending a lot of time at the bedside."
The question of whether older people coming into hospital are treated with respect, dignity and compassion is one of the main issues Health Secretary Nicola Sturgeon charged HIS with monitoring last year when she asked it to carry out inspections into the care of elderly patients.
There were four other key themes: the treatment of people with dementia or other cognitive impairment, the management of older people at risk of slips and falls, nutrition difficulties for older patients and the care of pressure ulcers, or bed sores.
Ms Sturgeon was responding to concerns over the care of elderly people in care homes – such as the Elsie Inglis scandal in Edinburgh, and the Mental Welfare Commission's Starved of Care report into the death of a patient with dementia who was deprived of nutrition over a lengthy period.
Announced to mark Dementia Awareness Week last year, the inspections were an extension of existing work by HIS inspecting hospitals across Scotland for cleanliness and infection control.
HIS has now carried out six announced inspections of older people's care in hospitals in Glasgow, Paisley, Edinburgh and Lanarkshire, five have so far been published. As of next month it will also carry out unannounced spot-checks to ensure hospitals are addressing the five themes and to demand improvements where they are not.
Although chief inspector Susan Brimelow does not have the power to enforce her decisions, in terms of sanctions or penalties against failing health boards, the boards are required to address problems thrown up by inspections, and staff at HIS are available to work with them to help them do so.
This makes the watchdog unique, according to Ms Brimelow, who says it is quite different from her previous position at the Care Commission, which has now been replaced by the Care Inspectorate. The involvement of lay inspectors also makes it different – members of the public go through a rigorous induction programme, before taking part in inspections covering two-and-a-half days, spending time at each hospital due for inspection and helping write reports on what they find.
Inspectors are recruited with an eye on their background and include people who have looked after elderly relatives at home. This lends meaning to the role of HIS as the eyes and ears of the public.
Launching the unannounced inspections will help, Ms Brimelow says. "I believe hospitals should be ready for inspection at any time. This also means if there are concerns on an announced inspection we can follow up, unannounced."
This is a technique which has been tried and tested on the longer-running "safe and clean" HIS inspection programme. "People look to independent inspection for protection," she adds. "We can't look at all of the five theme areas in two-and-a-half days, so we use a range of information we've got about a health board to decide what we might look at. For example, the public service ombudsman might have reported on poor pressure ulcer care in a health board area, so we might decide to pick up on that."
Going in to inspect one area of care doesn't preclude a mid-inspection switch, she explains. "If while on an inspection we are concerned about other aspects of care, like nutrition, we can move in to address that during the visit."
Areas of focus can also be suggested by members of the public. While HIS does not have a role in investigating complaints, the chief inspector has an online mailbox and encourages contact from patients and carers. "We welcome any concerns," Ms Brimelow adds.
Dr Coia believes the approach to inspection taken by HIS is a sign that scrutiny has grown up. Rather than slating individuals or management for failings, HIS works with them to insist on improvements, she says, pointing out that problems may not be to do with individuals anyway.
"From a staff perspective, when we are asking for improvement it might just be that the system is not fit for purpose any more. It is not individual people sometimes," she says. "That is one of the lessons of the C. diff experience, where we have reduced infections to nearly zero because staff have adopted different ways of doing things."
Nevertheless, it is clear that blaming the system cannot be used as a cop out. Asked if short-staffing, for example, might give a misleading suggestion of problems on a given day, Ms Brimelow disagrees: "Yes sometimes there is another side to the story, but I'm publishing reports without fear or favour based on what I see on the day." Staffing issues would be for a health board to address, she suggests, and it is not the job of HIS to know what is going on behind the scenes.
It adds up to more effective inspections, Dr Coia claims. "Scrutiny works much better if you get improvement, and we can be proud of our approach in Scotland. Scrutiny is a relatively crude instrument to identify something important. This is a mature approach. We could set up standards and say that is not good enough and hit everybody over the head. But it is better to say how would this improve if we do X, Y and Z."
Health boards and their staff then become partners in the improvement process, she insists, ultimately identifying problems and potential improvements on their own initiative. In the ideal world, we wouldn't need a crisis to come before we scrutinise anything," she adds. "In 100 years we might do ourselves out of a job."
