In this reflective account I will relate to a significant event, demonstrating how I have developed personally and professionally, focusing on the implementation of care and support. Rodgers (2002) suggests from Dewey (1933) that reflection is the process of “reconstruction and reorganisation of experience which adds to the meaning of experience”. Therefore analysing an experience, to develop your current knowledge, by reviewing your actions and assessing the experience to develop your own personal and professional skills in future practice. Hamill (1999) recommends writing reflection in first person using

Driscoll’s model of reflection

(Driscoll 2000).

The situation I have chosen to reflect on is an interaction with a patient who had been given a terminal diagnosis and had been informed the prognosis was limited. I have chosen to reflect on this account as it involved difficult communication which made me question my competency as a student and prior to the event I thought I would not be prepared to deal with it. (See Appendix)

As I had previously interacted with the patient on her admission, I have already communicated and developed a relationship with her. Groogan (1999) states that communication creates a relationship, with communication providing a holistic approach to caring for the individual to meet their psychological, social, spiritual and physical needs. I was therefore able to recognise that something was wrong and identified that she wanted somebody to talk to. Forrest (1989) identified core elements of nursing as picking up on cues and the importance of “being there”.

Jarrett and Payne (1995) reviewed literature on nurse-patient communication and concluded that there is a need for nurses to make an assessment of each individual situation, so that they are aware of whether the patient desires the information. Relating to the assessment I made of the situation I was aware the patient wanted to talk and realised that she was not asking for information but wanted someone to talk to.

During the event I felt anxious and nervous about how to react and communicate with the patient as I had never been in that situation before. Buckman (1998) identified health care professionals experience fear of the untaught and fear of saying “I don’t know”, the experience of showing emotions was also identified and throughout the situation I felt empathy towards her. Empathy is defined as the mental capacity to appreciate another person’s feeling without joining them, understanding patients experiences. (Hojat et al 2001).

Sieh et al (1994) states that special emphasis is placed on listening and empathy skills in the training of nurses. However, in the situation I questioned my competencies within my communication skills as I thought I was unequipped within my training to provide the care and support the patient required. On reflection, I identified that I worked within my role and limitations as a student to assess the situation and act as appropriate.

Reflecting on the situation I have identified that non-verbal communication played a large part of the experience. Non-verbal communication includes the use of eye contact, flexibility of facial expressions, the use of gestures, use of touch, pausing to allow a response timing and body posture (Purnell 2000). This definition relates to the situation as I was sat at her bedside when she began to cry, and then she said to me “I am dying aren’t I?” She put her hand out and I just comforted her by holding her hand.

The expression and discussion of feelings of loss and grief can be very difficult for patients with incurable disease and their families (Clements- Cortes 2004) When she asked me the question “I am dying aren’t I?” my first thoughts were to ask a Staff Nurse to come and speak to her, but I felt as if she had chosen me to talk to and that I couldn’t have walked away to get someone. Although I didn’t answer her question, I felt as though I was supporting her by being with her and as I knew she understood her prognosis and felt that the question didn’t need an answer.

On reflection, the event directly impacted on the patient, me and my role as a student and my mentor. I feel that the patient was able to express her feeling and emotions and I was able to provide care and support within my role. I identified that I assessed the situation and made decisions to provide the best possible care and support for the patient at the time. The situation made me question my ability however it developed my communication skills which are transferable to all aspects of nursing.

To enable me to reflect on the situation I used literature as part of the reflective process to read around communicating in palliative care, the nurse-patient relationship to continuing development and promote learning as Glaze (2001) reports the use of literature is used as part of reflection to promote learning by reading around the topic.

Following the event, I informed my mentor what had happened and she said she was aware of the situation and felt that I had dealt with it very well. We reflected on the event and I felt as though at the time somebody could have came to make sure the situation was ok but following the discussion my mentor was aware of the situation and that she would have intervened if necessary. Following the discussion I felt supported by my mentor, although the event was emotional and sensitive I feel it was a positive learning experience.

Benner (1984) describes stages of practice from novice to expert, at this stage in my training, I am working towards an advanced beginner, although I recognise this in this situation I had no experience of communicating in difficult situations and for that reason I felt like a novice. For this reason I feel as though my mentor could have identified my weakness in this area and at the time and acted sooner. The role of the mentor is to assess and support the student in practice (NMC 2008) on this occasion I felt my mentor fulfilled their role after the discussion following the event, however during the event I felt it was just me and the patient, and I acted within my role.

In conclusion, I have recognised the importance of the nurse-patient relationship and feel the experience at the time and reflecting on the experience has had a positive impact on my personal and professional development. Understanding that within the role of a nurse, communication is not only about information provision but about adapting your own skill to assess situations and act appropriately. In relation to implementation of care and support this experience highlights the nurse role to provide emotional support to continue to communicate effectively.

I attended a core group meeting for a family with complex needs. Parents Poppy and Richard had struggled to overcome a class A drug addiction and that there were grave concerns about the wellbeing of the 4 children in the family home. I sat opposite Poppy across a small table as this was the last available seat in the room. Richard was unable to attend but it had a very positive start for Poppy who discussed some of the improvements since the last official meeting. She appeared content and motivated to ensure things continued to improve. I was aware that an important discussion was going to take place about a serious incident which had occurred within the family and had been observed by a health visitor visiting the family next door. The purpose of the discussion was to support Poppy to understand the risks of leaving children unattended in the car and readdress the on-going issue of smoking around the children in confined spaces. The issue was broached by the social worker and Poppy immediately expressed unease. She denied having been involved until Poppy was informed it had been witnessed by another health visitor. Poppy became very angry, very quickly and made reference to the name the health visitor (her name had not been disclosed in the meeting). Her anger was then directed at my community practice teacher and me as the health visitor/student in the room. Poppy maintained intense eye contact with me and when I glanced away she noticed and it escalated her anger. Amongst the shouting and swearing Poppy was asking why Health visitors always interfere with her family and she was expressing that there was nothing wrong with what she was alleged to have done. As the main receiver of Poppy’s upset I tried to put active listening skills in to practice.

Chosen Reflective Model and Rationale:

Reflection is described by Boud et al (1985 p43) as ” a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation” . It is deemed a particularly valuable tool within the health profession for many reasons. Reflection is a tool which can be used at all levels within the health care setting and is arguably imperative within practice (Ralphe et al 2011). It facilitates critical thinking (Cotton 2011) and by scrutinizing experiences professionals are then able to decipher the evidence within their own practice.

Moreover it supports practitioners to make more sense of difficult and complex situations (Driscoll and Teh 2001). The collection of knowledge of individuals and groups through the form of refelction helps people to look not only at the situation but at how to understand it enough to be able to commit to improve similar situations which may arise again. Thus leading to improved practice (Ghaye and Lillyman 2010)

Examples of reflective models include Gibbs (1988), Johns (2004) and Driscol (2000). Johns’ model is recommended for more complex reflection and decision making (REF). On one hand this would work well as a basis for this assignment however the model looks at the situation which has been resolved and it could be argued that it does not consider how the situation can be taken forward (Rolfe 2001). Although this could be adapted the Gibbs model of reflection (Gibbs 1988) has been chosen as a guide for this assignment. Despite being a fairly straight forward model, it is favourable because it aids a clear description of the scenario, analysis of feelings, evaluation of the experience, analysis to make sense of the experience and conclusion for each point that will be reflected upon. This enables careful consideration on what I would do if the situation occurs again.

Communicating in Difficult Circumstances and Relevance to Health Visiting:

According to the Department of Health (2007) one of the key elements to health visiting practice is to deliver the healthy child programme (Department of health 2009). This outlines the role of the health visitor and this includes the need for the health visitor to reduce health inequalities and protect children at risk (Department of Health 2009). The distressing conversation for Poppy was aimed to protect the children from potential harm caused by cigarette smoke and also to protect the children from the harm of being left unattended in a smoky car. It was acknowledged that smoking cessation had been suggested to Poppy but denied with such ferocity that the idea was to put things in place to protect the children from being harmed as a result of her smoking. After all as professionals we have to remind ourselves that Poppy has a right to smoke if she chooses to. The safeguarding of the children is paramount and therefore despite it being a tricky issue to address, it was an issue which was vital to work with in order to safeguard the children.

It is important to recognise that delivering these messages set out in the healthy child programme (2009) are not always straight forward. The people at highest risk of poor health are often those who have a lesser understanding of the consequences of their actions on the health of themselves and their families. They are perhaps less likely to comprehend the information which is delivered to them and the fact that this information is often changing (Knai 2009). Good communication is therefore crucial. Communication is defined by Porche (2004 pp266) as

The transfer of Information and the understanding of the information from one individual another. It is the process through which individuals share thoughts, ideas, facts, beliefs, values and traditions.

The department of health (2012) recently published Developing the Culture of Compassionate Care, which highlights Communication as one of the 6 C’s (Care, Compassion, Competence, Communication, Courage, Commitment) required to maximise compassionate care. It acknowledges that good communication skills contributes to better listening which results in people receiving care feeling valued and therefore happier with the service they receive (Department of Health 2012).

Focusing on communication in difficult situations is very relevant to Health visiting practice as there are frequent barriers which can effect delivering the public health messages. In this case the barrier was Poppy’s resistance as a loving Mother to acknowledge the risks which her actions may have on her children and the emotions this consequently provoked creating a difficult situation in which to communicate not just the public health messages but to support Poppy in de-escalation. Resistance to accept information and support from health visitors is an on-going issue (REF) so having the opportunity to critically reflect on the situation will support me to ensure better practice in futur

Eye Contact

Initially Poppy seemed calm and positive about the progress she had made with her children avoided eye contact. However when angry, Poppy maintained strong eye contact with me in particular. I was surprised at how intimidated I felt, not by the shouting and verbal abuse but by the intense way in which Poppy was looking at me. I glanced away and looked towards my community practice teacher. This move that for me seemed quick and subtle had a profound effect on Poppy and she demanded I look at her when she is talking to me and this was followed with a threat.

As specialist community public health nurses it is important to recognise that communication goes way beyond the verbal conversations that we have with people. Nonverbal communication plays a very strong role in the impressions that we give to people therefore having an understanding of what happened with Poppy is key to furthering my communication skills and awareness in future.

Non-verbal communication is profound. Eyes and eye contact are a major part of non-verbal communication and many messages are consequently sent and received by the eyes (Sieh and Brentin 1997). The person who is listening holds eye contact with the speaker in order to express that they are listening and taking on board what the speaker is saying. The speaker holds eye contact with the listener so that they will know that the conversation is being directed at them (Lerner 2002).

It is a real challenge to define normal eye contact as it differs from person to person depending on personal preference and aspects such as culture. (REF something on culture). It is not possible to create a text book advising when to look and how long for (Rungapadiachy 1999). Therefore responses to eye contact are open to interpretation and could lead to confusion within communicative situations (Sieh and Brentin 1997).

Eye contact can have a positive impact on people. A good level of eye contact from the listener can make the person speaking feel as if they are being listened to and listener is interested and focused (Rungapadiachy, 1999). Alternatively, any form of eye contact can cause some people to feel uncomfortable, self-conscious and threatened (Rungapadiachy, 1999). Minimal eye contact may indicate lack of interest (Sieh and Brentin 1997) but it is important to acknowledge that eye contact may be less prominent when engaging in difficult or intimate topics (Rungapadiachy, 1999). Knapp (1978, cited in Rungapadiachy, 1999, pp206) recognises that when a person is disapproving of something it can be displayed in aggressive and intimidating eye contact. Furthermore early signs of anger can be shown via intense and threatening eye contact (Neild-Anderson et al 1999).

Poppy initially avoided eye contact. She may have felt self-conscious being surrounded by professionals and despite the discussion being originally very positive, the subject matter was also intimate and personal. Similarly possible that she was able to anticipate what was about to be said.

As Health visitors the heart of what we do is safeguard children physically and emotionally. The information discussed was vital within our role but it was not easy for her to deliberate and acknowledge. The intimidating eye contact displayed could have been because she was feeling intimidated or she was not accepting of the information being given to her. Moreover, I broke the eye contact momentarily and this may have upset the foundation of the conversation. For Poppy this could very easily be construed as non-compliance to listen on my part (Kidwell 2006).

If we feel that something is unacceptable then it is likely that our eye contact will decrease (Rungapadiachy 1999). I acknowledge that I looked away from Poppy whilst she was communicating with me. Consciously I feel this is because I felt intimidated. However perhaps subconsciously I was not accepting of what she was saying.

I attempted to communicate to Poppy through non-verbal communication that I do care and I appreciate that the situation was not an easy one for her. This is much like the view of Chambers and Ryder (2012 p106) who acknowledge that “many nurses have become very skilled at communicating messages and meaning without words”. However in this case, either I was not portraying myself in the manner that I intended, or it went un noticed as a result of Poppy’s heightened state of anxiety and upset.

At the time I did not consider that Poppy could have misinterpreted my eye contact for staring. Poppy’s behaviour was intimidating but this did not exempt her from feeling intimidated herself. It is possible she felt under attack as a result of the raised concerns and prolonged eye contact on my part could have been threatening (Duxbury, 2000).Moreover, averting my gaze suddenly, may also have signalled fear in me which could also have distracted Poppy from getting her point across (Manos and Braun 2006). Alternatively I acknowledge that eye contact is also natural process and the anger which Poppy displayed did frighten me thus triggering a fight or flight reaction (Manos and Braun 2006). I did not escape physically but there was a shift in my gaze in order to avoid a threatening glare and it could be argued that this does not assist good listening.

Although it was not possible in this situation because of the room space, I understand the importance of positioning within a meeting. I was positioned directly opposite Poppy which meant that I was the centre of her vision and she of mine. This meant that where less intrusive peripheral eye contact may have worked better, I was holding what could have been construed intimidating contact (Duxbury, 2000).

My Community Practice teacher fed back that my expressions and levels of eye contact were acceptable and skilled. She viewed the reaction as unavoidable because of Poppy’s nature and the topic of the conversation. I acknowledge that there were a number of factors which triggered Poppy’s anger and it is because I deem eye contact so important that I have prioritised it. It is very difficult to know whether it directly correlated with the escalation of her emotions and if it did which of the above discussions applied to her. However as a result I am more aware of different personalities and how communication methods can be interpreted and it is this which is so vital for future practice.

Seih and Brentin (1997 p5) reinforce this by stating “Being sensitive to your own eye contact patterns and the patterns of those with whom you communicate will help you be more perceptive of what is occurring in the communication process”,

Active Listening

I was aware that Poppy needed support to deescalate. I was not confident addressing this myself despite having had years of experience deescalating distressed people who displayed challenging behaviour. This was different. There was pressure on me as Poppy had targeted me and I was feeling increasingly intimidated by what was happening. Whilst Poppy was shouting I nodded a few times so she would feel listened to. She made some unpleasant threats to my community practice teacher and me and was suggesting that there was no problem with leaving children unattended in a smoky car or in smoking with them on her lap. I was equally careful as I did not want to give the impression that I was condoning what was being said. When active listening was used Poppy did respond calmly on occasion. Verbal contributions which I made in response to Poppy included:

“Am I right in thinking that you feel that your privacy has not been respected?”

“Are you saying you feel health visitors don’t think you are a good mother?”

Active listening is central to good interpersonal skills (Wondrak 1998). Where listening may be deemed passive when a person is talking and another listening it is in fact very active. Active listening is defined by Arnold and Boggs (2007 pp201) as “a dynamic, interactive process in which a nurse hears a client’s message, decodes it’s meaning, and provides feedback to the client based on their understanding of what has been said”. It is deemed an empathetic means of communication where the listener understands and shares the feelings of the person talking whilst recognising they are not their own feelings and opinions (Balzer-Riley 2008.)

A significant advantage of active listening is that it prevents misunderstanding. By relaying back to the person what they say they are feeling it ensures that there is no guess work and thus confusion over what is being said (Balzer-Riley 2008). Active listening is therefore a useful tool in attempting to defuse situations involving conflict (Reznic et al 2012). It allows the individual to communicate and get a response when conversation is not appropriate. In these instances the use of active listening enables the person talking to feel like they are being engaged with but without bombarding them with information they are not in a position to receive (McBride and Maitland 2002).

Actively listening gave me the opportunity to be proactive. I was embarrassed and threatened and felt that it was my fault that Poppy was upset (as a result of me diverting eye contact). I had a personal battle because on one hand I felt sad for Poppy as she was clearly distressed and I understand that she has a lot of difficulties in her life. On the other hand I was shocked that she said that she did not care about the issues in hand. It could be argued that she was being defensive because she felt uncomfortable in the situation; however the issued in hand were very real and reflected what she was saying.

As theory suggests, active listening in this instance was useful. It enabled Poppy to feel that she was being listened to and perhaps even understood. Although Poppy appeared fraught, the fact that I was relaying to her what she had just told us seemed to gradually calm the situation. It was my hope that by actively listening we would eventually get to a point where Poppy was ready to talk and receive advice and information. I acknowledge this was perhaps naïve but Poppy was empowered enough to make the decision to walk away to calm down. Despite the challenging situation there was no obvious misunderstanding to be resolved, more a serious issue which needed to be addressed.

I would like to have been able to offer Poppy some space to calm down but this would not have fitted in with the core group. I was very conscious that there were a room full of people watching and that this would not have supported Poppy to deescalate. It was a relief that by actively listening to Poppy, my CPT was able to encourage her to make the decision.

In contrast to the recommendation I made for future practice regarding eye contact, it is recommended that the listener sits squarely in front of the person talking and maintains good eye contact when engaging in active listening (Duxbury 2000). I would agree that this is the case when the conversation is calmer however I learnt that in this scenario this was not appropriate as I was sitting directly in front of Poppy. The verbal communication I contributed through the active listening process had a more positive impact than the way in which I was sitting. Linking in with the above reflection about eye contact, it is recommended to maintain good eye contact with the person talking if it is within their cultural boundaries (McBride and Mailtland 2002).

Active listening will be a dynamic part of my communication methods in future and I aim to learn more about the effects of active listening on people who receive care. I would like to attend further training in this area as I now see it as a vital aspect of communication and I acknowledge that active listening skills can be improved. As an active listener, sensitivity is a key concept and I believe it is a method which could be particularly beneficial when communicating with women who are suffering with post natal depression.

The concept of active listening is consistent however the ease in which we do it will vary from case to case as will the outcome. The situation described above was tense and it took self-discipline for all those involved not to engage in a conversation which could have caused the incident to worsen further and the non-verbal communication methods varied from what is recommended. In future I will be aware of adaptations which may be required rather than solely facing them at the time. Ultimately active listening will be valued as much as any other forms of communication.

Leadership

As previously established, communicating in difficult circumstances and communicating information which may be difficult for families to acknowledge is not unique in health visiting. As health visitors embrace new leadership challenges it is important to acknowledge the above reflection and consider how what has been learnt can be disseminated through teams. Throughout the SCPHN course communication skills such as active listening are taught and these skills are useful not only in communicating with families but also with teams. Building relationships and having the ability to communicate and negotiate successfully are key skills in leadership and being able to gage appropriate eye contact and active listening both come under the umbrella of communication (Adams 2010). Effective communication is a core competence in good leaders (Sobieraj 2012) and this is demonstrated in the NHS Leadership Framework (REF) which prioritizes communication as a key component.

Recommendations for future Practice as a leader:

• Further training in non-verbal communication skills needs to be available to teams as this will benefit communication used with families and further professional relationships.
• Non-verbal communication skills should be discussed with all of the team regularly for example in team meeting s or supervision and used as a measure for understanding and success.
• Critical reflection on various scenarios should be carried out in order to further understanding in these areas and support the application of evidence based practice.
• Empower team members to communicate effectively and understand the importance of non-verbal communication strategies
• As a leader I will take what I have learnt with regards to this reflection and use the skills in communicating with both families and team members.

When making recommendations be sure it doesn’t start to sound like a shopping list – balance this with the demands and pressures of the real world. Maybe find examples of where these suggestions have been put into practice…this helps to justify your recommendations etc.

The above recommendations support the notion of leading with compassion. Offering team members with the compassion we want them to provide enables each individual to feel empowered to give effective and compassionate care of which non-verbal communication is so important (Sobieraj, 2012).

Since its launch in 1948, the NHS has evolved to turn into the world’s largest publicly funded health service. It is also one of the most efficient, most egalitarian and most comprehensive. The NHS in England is the biggest part of the system by far, catering to a population of 51m and employing more than 1.3m people. Although funding is provided centrally by national taxation the NHS services in England, Scotland and Wales are managed separately. (1)

When the NHS was launched in 1948 it had a budget of £437million (roughly £9billion at today’s value). In 2008/9 it received over 10 times that amount (more than £100billion). Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment and training costs on the one hand and medical equipment, catering and cleaning on the other. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas. The money to pay for the NHS comes directly from taxation. According to independent bodies such as the King’s Fund, this remains the “cheapest and fairest” way of funding health care when compared with other systems. (1)

The Department of Health controls the NHS. The secretary of state for health is the head of the Department of Health and reports to the prime minister. The Department of Health controls England’s 10 Strategic Health Authorities (SHAs), which oversee all NHS activities in England. These SHAs supervise all the NHS trusts in its area. The devolved administrations of Scotland, Wales and Northern Ireland run their local NHS services separately. The foundation trusts have been introduced recently to make sure that the people in the local area run these hospitals and the decisions are made to address the health issues that are of particular concern within the local population. (2)

The modernization of NHS was proposed by Lord Darzi. The vision is to improve the quality care rather than the quantity of care. The main consideration is to make sure that the NHS is patient centered and clinicians are placed in the front line for providing the NHS services. It also considers clinical governance with an emphasis on the accountability of the results. This model involves the formation of GP consortia and centralizing the services which are led by the GP. The proposal was supposed to free the NHS services from bureaucracy and political influence. The proposal plans to open 150 GP led services offering better health services to patients. There is a long standing debate between health care professionals, politicians regarding this new concept. It might provide flexibility for the GPs to provide health services prioritizing appropriately with a true representation within the local population. The introduction of the new GP led system has advantages and disadvantages which are discussed as follows.

Patient centered care and concordance:

Patients will be put at the centre throughout the decision making process. All the healthcare related issues regarding a particular patient are addressed with patient concordance. This new system allows the patient to choose the health service provider, choice of consultant led- team and choice of treatment. They can access information and make choices about their healthcare. The new system is an open policy where every outcome is discussed with the patient whether it’s good or bad. Concordance and compliance are main issues in improving the health care outcomes. For instance, if an osteoporotic patient does not like plain calcium supplements because of taste will not take the medicine even if it is prescribed repeatedly. Fruit flavored tablets might be an option. Patient would comply with medication and which would improve the clinical outcome. The patient has the right to know what procedures are being carried out, disease condition and treatment plan.

The concept of discussion of health issues between patients and clinicians is interesting. This will provide an opportunity for the clinician to address the healthcare issues at any time, Patient reported outcome measures (PROMS) can be helpful in assessing the improvement in the health care outcomes. The availability of information in future will improve accountability (2). In contrast, the new system expects the health authorities to be open if something goes wrong and report to improve the quality of care. However, there is a chance for underreporting and also lack of standardization of the information collected. True national extrapolation of the collected data might be difficult due to varied standard operating procedures, policies and different target population. The idea of making sure that the patient can access their data and transfer it to the third parties is daunting and not cost effective due to the data protection and technological investment issues.

NHS and the concept of ‘improving healthcare outcomes’

NHS at present includes clinical staff who are among the most talented in the world. All the healthcare decisions are based on the evidence-based medicine. NICE funds for the clinical research for the publication of evidence- based medicine(2). Findings showed that poor health outcomes are achieved in some areas such as respiratory disease, stroke and cancer. The underlying risk factors were considered to be the cause. For example, smoking can contribute to the cardiovascular disease, COPD and cancer. Much emphasis was put on the public health to address these health care outcomes. The current NHS has predesigned services and expects the patient to fit into these services rather than adjusting services around patients.

NHS remodeling will focus on removing the layers of management (administration staff) and enhance the clinical staff. Under the new system NHS will be accountable for all the clinical evidence- based outcome measures and not the process targets. The new system removes the previously set targets without clinical justification. NICE (National Institute of Clinical Excellence) sets the performance standards on which the NHS care quality is based on. NHS commissioning Board will have the responsibility to eradicate any inequalities in the outcomes from the health services.

NHS outcome framework addresses effectiveness of treatment, safety and patient experience. The quality care outcomes for the target groups such as elderly, children and mental health are difficult to quantify. International comparison on avoidable morbidity and mortality is difficult as the population used for comparison might be different from the local population and also varied health care issues.

Emergence of GP consortia and consultant burden:

The new system proposes to establish GP consortia and transfer of responsibilities from the primary care trusts (PCT). This will provide more options for GPs to prioritize the health issues and allocate the funds to address the health issues within the local population. The system was introduced to make sure that the taxpayer’s money is used appropriately by the GPs, health care professionals and commissioner for the best possible quality outcome. NHS commissioning expects the provider to manage the healthcare data with contractual obligations. The downside of this is that the GPs have to be more of data collectors in addition to their clinical commitment to treat patients. This might add additional burden to their already existing workload.

Patient can chose to register with any GP. This will have a significant impact on surgeries because if a GP surgery has higher number of patients this will add extra workload to GPs and possible increase in waiting times for the patients. The appropriateness of the healthcare data collected might even be difficult. This is true if the patient from a different locality decides to join a GP away from his geographical sector and the patient’s health condition will represent the local population which should not be the case. However, this can be helpful for providing healthcare to the acutely ill patients during GP out- of -hours.

GPs are healthcare providers primarily. They are handed the responsibility to co-ordinate patient care. This will require extra time to negotiate with other health care providers in case of patient referrals. This will shift the primary role of a healthcare provider from treating patients to become a financial negotiator.

The quality of care by the provider is based partly on the patient’s response and the incentives are based on the implementation of NICE standards. NHS commission can impose contractual penalties to the service providers. This will add to the already existing pressures to meet the health care outcome targets. Moreover, the incentives are based on the number of registered patients. GP surgeries in small villages with less local population might not get enough money because of this system. Prices and payments are considered on the basis of most efficient, high quality services. This is dependent on the local population being treated. Highly affluent community with healthy life styles might show better outcomes with little GP intervention compared to deprived community with lot of health care issues needing addressed.

Government’s white paper ‘Equity and Excellence’ also states that patient can choose a particular consultant and medical team for his or her medical condition to be treated. This can be difficult for the GP to decide if any particular procedure needs to be done on the patient. The consultant chosen by the patient might be expensive compared to another consultant GP might prefer. This might lead to overspending of the budget. Secondly, if all the patients are considering to be treated by a particular consultant, there is a possibility of increased waiting times which can have significant effect on health care outcomes. ‘Monitor’ system will look at the competition between providers but once the patient’s decision has been considered it might be difficult for the GP and the Monitor system to come to an agreement. (2)

Impact on NHS and healthcare staff

Proposals for commissioning education and training for healthcare professionals locally and nationally will have a significant impact on the work procedures and the knowledge gain. The structure and content of training, quality standards are reviewed by the professionals which can have a major impact on the healthcare outcomes. NHS pay and staffing is allocated to the healthcare employers. Government plans to set the pay for all the NHS employers by consultation with healthcare employer. Staffing and affordability decisions are made by the ministers with the help of healthcare employer. The aim was to decentralize the system but this seems impractical as the decisions such as staffing and affordability are still made by the ministers together with the healthcare employers.

Government plan to decentralize the system and cut the costs of health bureaucracy might have a significant impact on the budget. However, the implementation might not be fair as this might result in loss of jobs and also transitional costs until fully implemented. The implementation of new system will liberate NHS from meeting targets such as 98% requirements for A&E waits and associated performance management bureaucracy(2). Eradication of these targets will reduce the pressure.

The royal pharmaceutical society has opposed to any further regulations on pharmacies unless it improves the patient safety. Pharmacists are already under pressure dealing with the pharmacy related tasks along with the public health. RPSGB is concerned regarding the commissioning of services by NHS commissioning board, GP consortia and local authorities. The society is concerned about the communication between these partners so that patients can receive high quality care. It also asked to define the functions of ‘Monitor’ system in detail. The society also aims to strengthen pharmacist role in addressing public health issues.

Conclusion:

The white paper published with the intention of improving the health care outcomes. The main focus was to make the health services autonomous without political interference and influence. The proposal is based on the quality of care rather than the volume. Information revolution is supposed to bring a radical change for the dissemination of patient’s healthcare information. The GP consortia will be responsible for the care provision in the absence of primary care trusts. Local health issues are addressed and treated according to the standards set by NICE and NHS commissioning boards are responsible to meet the national health targets. This new GP led system will have significant impact on the GPs themselves and other healthcare professionals. GPs will become financial negotiators rather than healthcare providers. It will be interesting to see the contingency plans if the new system fails as this is the first time NHS is undergoing such a massive change.

What is Safeguarding?

(Introduction)

This assignment will explain the definition of safeguarding, by showing clearly how safeguarding links to health and social care. It will use examples of legislation to explain safeguarding policies and procedures which are created that are used in health and social care environments, and it will illustrate how mistreatment of others is reported correctly.

(What is safeguarding?)

Safeguarding means to prevent an accident, injury or maltreatment of other people. The term safeguard is used to describe the things we do to stop something from happening, and the actions we take to continuously stop someone from getting injured or abused. Safeguarding procedures are in place in a lot of industries where vulnerable people, such as young children or the elderly, are worked with. These procedures cover problems such as fires or slipping on wet floors, with solutions to put signs to warn of a wet floor in regards to slipping, and having common fire extinguishers with diagrams of how to use them in regards to fires. Safeguarding is a large factor in health and social care as the duty of caring for residents of different ages is to protect them from injuries and abuse. In care environments such as hospitals, there are many accidents that are able to occur if safeguarding policies are not followed. An example of a serious accident that can occur in hospitals is a mix up in medication, which could cause a patient being given medication that was meant for someone else. This could be potentially fatal in a worst case scenario, or the patient has a heightened risk of developing another issue adding on to the one they already suffer with. To prevent this, the list of medications and patients could be double checked to make sure that the right medication is given to the right patient. This is why safeguarding policies and procedures have to be in place so the chances of this happening are reduced drastically, and patients in a hospital, or residents in a care home, can be looked after properly.

(How legislation influences safeguarding)

The Care Act 2014 is distinct towards adults who are in need of care and support needs. This includes adults with learning disabilities and adults with joint pains, such as severe arthritis. It relates to safeguarding as it’s sole purpose was to develop clear safeguarding policies. It aspires to do this by listing clear definitions of abuse and neglect. It also developed policies to help with the safety of this group of individuals. This makes it easier for medical professionals to define when someone has been abused or neglected and to report this in a correct manner, and it makes it easier for a victim of either of these things to seek help and be brought of out those circumstances.

The Health and Social Care Act 2012 is definite towards individuals accessing care services, such as care homes or hospitals. This piece of legislation also takes into account the workers within these services. The main aim of this act is to help individuals who access these services get the highest possible standard of care as well as helping to stop widespread issues such as abuse and neglect. Due to this Act, CCG’s have been appointed to stop maltreatment happening to individuals. This relates to safeguarding because a specific group of people, such as persons with learning disabilities or terminally ill individuals who are vulnerable, are being protected from harm.

The Data Protection Act 1998 is specific to a large group of individuals, as it regards people’s personal data, and it is aimed towards anyone who has personal data held by a company or a service, such as a hospital or a care home. The main reason for this act is to achieve higher security of people’s personal data, so there is a reduced chance of a data breach and no-one from the public can access another person’s details, such as their phone number or address. This relates to safeguarding as abuse is prevented because victims who escape abusive relationships can be confident that their personal details will not be able to be released to someone who has abused them in the past. Another act that relates to this one, and strengthens data protection is the General Data Protection Regulations 2018.

The Equality Act 2010 is definite towards any individual that may be discriminated due to a part of who they are, such as their gender, or their race. The purpose of this is to bring all past legislation regarding discrimination together into one piece. Also, it strengthens some parts of old legislation and adds new factors. The Equality Act 2010 covers disability, age, sex, gender reassignment, race, sexual orientation, religion, marriage and civil partnership and pregnancy and maternity. This relates to safeguarding as it helps create an equal society, so it protects people from being attacked because of their race. It also helps give young children a stronger voice, as children are found to have a smaller voice than older people. People with disabilities are often more vulnerable to abuse because they are often not believed when they try and speak to someone, but the Equality Act 2010 changes this. People of different genders also face less discrimination as they can sometimes face stigma for the jobs they go for, such as a female going into engineering or a male going into hairdressing.

The Children Act 2004 is distinct to children with deteriorating emotional and physical health and is at risk of neglect or abuse. The first act for children was the Children Act 1989, which was specific to children at risk of harm. It aimed to put the child first in any case, and courts would not give orders unless to do would result in a better wellbeing for the child. It also introduced Section 47, which means a duty to investigate. This meant that any calls or referrals to Social Services would have to be investigated. The reason for the introduction of the Children Act 2004 was because of the death of 8-year-old Victoria Climbie, who was beaten by her Aunt and Uncle. She was never deemed as a child at risk from abuse because each time she obtained an injury, she would visit a new hospital or GP and there was a lack of communications between hospitals and the authorities. The Children Act 2004 was put together to ensure that all operations that are involved with a child abuse case would communicate with each other. Around this time, the government introduced something called ‘Every Child Matters’ which was a list of things that a child should be, such as staying safe and being healthy. It relates to safeguarding because it strengthens child protection laws and helps protect the physical and emotional wellbeing of the child, preventing further abuse or neglect from carrying on.

Today, it is debatable whether the Children Act 2004 served the purpose which it was created for, as since the date of its passing, there has continued to be cases where young children have been abused or neglected and ended up dying from this. In 2007, there was the case of Baby P, a one-year-old baby who died from his injuries inflicted by his mother and her boyfriend. His mother would cover his bruises with chocolate to be deemed unsuspicious by social workers. The doctors failed in adequate care as he was sent to hospital with a broken back, only for doctors to refuse to check him due to him being in a distressed state. On the 3

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August he was pronounced dead after he was punched with such force that he choked on one of his teeth that fell out because of it. In 2012, there was the case of Daniel Pelka, a 4-year-old boy who died after being starved and beaten by his mother and stepfather. He often went to bins for food, yet this was never questioned properly by his school. Both of these cases question the ability of the Children Act 2004, as many opportunities were missed by social workers, police and schools to investigate efficiently.

(What is the relationship between legislation, policy and procedure?)

Legislation is a law or a set of laws that have been passed by Parliament. The word is also used to describe the act of making a new law. (Legislation, 2019). Legislation is suggested by the elected Government, and is passed through by a series of votes which occur until both the House of Lords and the House of Commons agree that the bill is good. After the legislation is passed, companies and services write policies to relate to the new law. Policies are the written standards that need to be followed so the legislation isn’t broken. Procedures are the criteria that is written within the policy to meet the requirements of the new law. They relate because it is a chain of reaction to a problem or event. This means that the initial reaction to the problem or event is legislation, such as the death of Victoria Climbie, which was reacted to by the release of the Children Act 2004. Because of this reaction, policies had to be made which is where the procedures are written down.

(What policies and procedures relate to safeguarding?)

In schools around the UK, they have the attendance policy, which sets out a list of instructions for members of staff to follow is a student is absent and they haven’t been notified. This was written due to the Human Rights Act 1998, which stated that people have a right to an education. The procedure members of staff follow if a student isn’t in and no one knows why, is to ring the student or the parents of that student and invite them to a meeting. There is also the Data Protection Act 1998, which caused confidentiality policies to be written in any service such as hospitals and schools, or companies that provide a service, such as care homes. In college, the procedures of this policy are to lock the classroom door when they are leaving, and to turn off computers when they are not being used. Another piece of legislation that influenced policies and procedures was the Equality Act 2010. This Act stated that everyone is to be accepted no matter their race, sex, gender assignment, disability, age, pregnancy and maternity, marriage and civil partnership, sexual orientation and religion. The policy that was made due to this Act was the anti-bullying policy, which was made to prevent bullying of anyone in relation to this Act. The procedure for anyone who was found bullying someone else was a meeting with a member of staff as a first warning, but if they persistently ignored the warnings, they could have a risk of being suspended or expelled. The statutory principles of the Mental Capacity Act 2005 aim to protect people who lack capacity and help them take part, as much as possible, in decisions that affect them. (Falconer, 2007) The policy created from this Act was to hold assessments that help professionals observe the adult’s ability to make choices, the procedure being to assess adults and determine the result by taking into account their circumstances, and the view point of others.

(What are the signs of abuse?)

The definition of physical abuse is anything that has been inflicted on the body that could leave potential marks of any kind. Examples of physical abuse include smacking, pulling of hair and punching. Someone may be physically abused if they have deep, infected leg ulcers, burn marks on the back of their legs and cigarette burns on their forearms. Bruises on the body is also a big sign of physical abuse, as it is something that is abnormal on the body. Victims of physical abuse also have a change in personality, as they may appear more scared than other people, showing this by flinching whenever someone is near them. They may also be isolated more, and they could often apologise frequently for harmless things as they think that they won’t be harmed anymore if they say sorry. They may also have an increase in anger, or wear clothes that don’t reveal much skin in hot temperatures. Elderly people may also get water infections frequently if they aren’t being cared for properly, or they may suffer with bed or pressure sores.

The definition of emotional abuse is to inflict pain in a way that affects the victim’s psychological wellbeing, and causes them to suffer a lowered self-esteem, which could lead to mental health issues such as anxiety or depression. Examples of emotional abuse include bullying, coercive control, constant rejection and isolation from family, exploitation, stalking and persistent name calling. Signs that someone is being emotionally abused range from feeling unable to eat due to overwhelming nerves which can create a feeling of nausea, this is often known as anxiety. Due to this nausea, and the inability to eat, they may find themselves feeling ill as well as being unable to have a restful sleep. Personality changes also happen in people who have been emotionally abused, as they become more upset and often have a lowered self esteem. Elderly people may become more withdrawn from others, and feel drained of any positive energy which they may have had. This causes them to appear more quiet, especially when the person abusing them enters or is already in the room. Physical signs to emotional abuse range from insomnia to weight loss. They may also partake in strange behaviour, such as sucking, biting or rocking. (Effects of Emotional Abuse, 2019).

The definition of sexual abuse is any unwanted advances made in a manner that has a sexual purpose. Examples of sexual abuse include having nude pictures taken of you without consent, non-consensual sex, proximity, harassment or prostitution. A list of signs of sexual abuse include pain and bruises around the thighs, breasts and genital area and unexplained bleeding. (Wyatt et al, 2017). Indicators that someone has been sexually abused are serious illnesses such as sexually transmitted infections. Some younger women may even end up pregnant as a result of sexual abuse. Elderly people who have been sexually abused could suffer with problems regarding their pelvis, due to their bones being weaker than a younger person’s. They may also sustain bruising around their upper thighs or hips. They may also become socially and emotionally withdrawn from others, or engage in aggressive, unusual sexual behaviours. (The Nursing Home Abuse Center Team, 2019).

The definition of financial abuse is any money taken from a person without their consent. This means that money could be taken off a person who is offering it to someone, yet fails to have the mental capacity to understand what they are doing. Or, it could be taken off someone who thinks that they are sending it elsewhere. There are many ways that financial abuse occurs. It is often found that the elderly, people with learning disabilities, and young children are particularly vulnerable to financial abuse because they are more naïve to the dangers of the world. Signs of financial abuse is someone who always appears to have a lack of money, which can sometimes lead to them not having enough to pay bills. If someone was to look at the bank statements of someone who is or have been financially abused, it would be easily noticed that large amounts of money, sometimes thousands, are leaving their bank at one time. They may also feel distressing amounts of anxiety. Elderly people, especially those with dementia, can have their lives changed for the worse by financial abuse as they are unable to get the money back. This can cause them to be arguably more distressed than a younger person, which could cause health problems.

The definition of neglect is to deprive someone of basic necessities. It is usually found that someone who is being neglected will often be unclean and malnourished. Other examples of neglect include no attention, not feeding and not taking them to the doctor’s when it is necessary for them to go. People who have been neglected will often appear as bewildered or unclean. They may often appear to be needing a drink, as they are dehydrated. They may usually be isolated from other adults or children around them. Elderly people may live in unsafe and dirty conditions, such as having no working heaters in the winter or bedding stained with urine. They may be left dirty as a result of not having a wash as their main carer refuses to help them. Their main carer may even leave them out of sight in public places, making them find a way on their own.

(How do you report mistreatment of others?)

When an issue regarding abuse is disclosed, it means that someone witnessed the abuse of someone else, or was told about it by the victim. When something is being disclosed, it is important to remember certain details such as the the time and place of the incident. It is essential to report any disclosed information to a line manager right away, as if it is delayed abuse can continue to happen. It is important to not overwhelm the victim with questions, as it is the line manager’s job to take action regarding the disclosure. When a child discloses something, it is good to help them open up by making yourself look more approachable. This could be by changing your body language to something that is more friendly looking and open, rather than something that is stern or closed off. It is important to listen to the child and put away any items that could possibly be a source of distraction. When a child discloses something, you need to let them explain what occurred at their own pace as it could be incredibly difficult and traumatising for the child to talk about. At the end of the discussion, it is good to show that you have truly listened and understood by taking time to reflect back on what they have said. If something has gone on or been disclosed and it’s not an immediate threat, members of staff need to find a DSP, which stands for Designated Safeguarding Person. They are the first contact for staff to go to if they need to talk about an abusive event which they have been told about. This is called a referral, which is where someone tells you about something that has happened to someone else. The Designated Safeguarding Person is responsible for updating the safeguarding policies and procedures as necessary. They are also responsible for promoting a safe environment, supporting staff with concerns about a person and deciding whether the disclosure is plentiful enough to be referred to Social Services. In other cases, such as if a victim seeks medical attention, you need to call 999. If the abuse is life-threatening and taking place at that moment, then you need to call the police and ask for assistance. If you are concerned about someone, but you are uncertain over if there is a serious problem, then you can refer it to Suffolk County Council. Someone can unintentionally cause something to happen due to not understanding or having a lack of awareness and no or minimum staff training. This is referred to as an Act of Omission. Sometimes, there are extreme cases where everyone at an organisation, including the managers, are ‘in on’ the abuse happening to someone. This means that when professional bodies such as the Care Quality Commission come to inspect the organisation, they cover up the abuse which occurs to get good ratings from them. In this case, the correct line of reporting is an act called whistleblowing. Whistleblowing is where you report an issue regarding certain areas such as health and safety. You can inform your employer of the wrongdoing, but if they have not listened or you feel nervous to do so, you can go to a professional organisation, such as the Care Quality Commission if you work in a care home, to report it. If the information is about possible harm or abuse, a safeguarding alert is made to the local authority. In support of the investigation an inspection may be carried out, and other regulator official body may be notified if it is appropriate for them to look into the concern as well. (Raising a concern with CQC, 2019)

References

• Page 53. CACHE Technical Level 3 Extended Diploma in Health and Social Care. Linda Wyatt, Pete Wedlake, Maria Ferreiro Peteiro, Elizabeth Rasheed. Hodder Education- London.
• Effects of Emotional Abuse (2019) [ONLINE] Available at:
  
  http://www.nursinghomeabuseguide.org/emotional-abuse/effects
  
  [Date accessed: 30/09/2019]
• Falconer (2007) [ONLINE] Available at:
  
  http://www.hampshiresab.org.uk/wp-content/uploads/Mental-Capacity-Act-2005-Code-of-Practice.pdf
  
  [Date accessed: 25/09/19] (Page 20)
• Legislation (2019) [ONLINE] Available at:
  
  https://www.parliament.uk/site-information/glossary/legislation/
  
  [Date accessed: 25/09/2019]
• Raising a concern with CQC (2019) [ONLINE] Available at:
  
  https://www.cqc.org.uk/sites/default/files/20160108_Whistleblowing_quick_guide_final_update.pdf
  
  [Date accessed: 30/09/2019] (Page 4)
• The Nursing Home Abuse Center Team (2019) [ONLINE] Available at:
  

  Sexual Abuse

  [Date accessed: 30/09/2019]