The aim of this section, is to continuously add updates to the book, largely from USA, Australia, UK. This book does offer a template which may be used to replicate the work within other countries. Scandinavian perspectives would particularly be useful. If you wish to contribute , please do so by contacting Carol Dimon . It is not possible to re-write the book here, but to direct people to additional references. All issues within this book warrant further research.

There are so many more factors that are involved within the issue of poor care such as manufacture of drugs or blood supplies from private companies (lenin2u) or community services .There may well be no end to these updates .
This site has reached max capacity. Updates 2 on   (22.11.2014)



 Chapter 3 Care Homes

This list in the USA  (healthyliving), identifies differences regarding quality of care within care homes, between different states. There may be many reasons for this, which will be of relevance. States in USA, have different regulations and requirements. There are also cultural differences which may affect staff and patients, as this book discusses. For example, it is indicated within USA, that certain groups of people receive lower quality of care - in this case blacks (today.ucf ). This supports the work ethic theory that people must earn their care and are responsible for themselves.

"Residents in care homes for people with learning difficulties are  still being "doped up with medication."  Buchanan (2014) writes

" almost two-thirds of residents are given the drugs on a regular basis, rather than when required. The figures also show that more than a third of residents are subject to hands-on restraint." This problem is an international issue.

More poor care in British care homes exposed by BBC Panorama (2014) including--

"a woman slapped by a care worker who had previously been complained about for her poor attitude towards resident,

cries for assistance from a resident suffering a terminal illness ignored as she sought help for the toilet, and her call bell for assistance left unplugged on one occasion, a resident bed-ridden with a chronic illness left lying in his own excrement after two care workers turned off his call bell without assisting him" (BBC News 2014). Following the Panorama reports of the home, which previously had been given a good CQC report , one member of staff was dismissed and 7 suspended. The home had been reported by staff termed "whistleblowers". Again it is important to know exactly who owns the care home and thus who is responsible (Lenin Nightingale); Anglia Retirement  homes was owned by one owner but the home is now owned by private equity trust August Equity which does not tell us who the actual owner is. According to Panorama the Government is considering requiring care home Directors to be legally responsible ; this is so needed. Nor do we know what happened to the home manager, if she was registered or not as she should be, and what the staff level was for the 98 residents within the residential home.

Care home closures, along with the rights of residents who live within them, must be considered . Care homes may close for various reasons, - failure to meet care standards, bankruptcy, or within the UK many Local Authorities are ceasing to run them . There have been cases of residents who have refused to move under such circumstances but are eventually forced out by security guards .A 101 year old resident   unsuccessfully  challenged Leicester City Council in court (2013) (Local Government Lawyer 2014)."The local authority argued that the claim had not been brought promptly and that no good reason had been put forward to justify the delay so that permission should be refused. It also rejected all three issues raised by the claimant’s legal team" (ibid).The lady had lived in the home since 1999 and it is well known that moving homes may adversely affect residents.

The need for Registered nurses in nursing homes is  a matter for debate. In NSW Australia, it is proposed not to require them at all in nursing homes (2014). Does the issue largely concern cost? In the UK we have nursing homes or residential homes depending on level of nursing need of residents. Residential homes do not require registered nurses .according to regulation. As this book discusses, there are indications in UK, that nurse training does not adequately prepare nurses to work in nursing homes. Following  a campaign (nurseuncut2014), an 18month reprieve has been gained regarding the issue of needed  a nurse in nursing homes. As discussed within the book, this situation may well eventually arise which could well have implications for the need for nurses at all.

In the USA some nursing homes have not had  a nurse at all on duty 24 hours  a day . Whilst regulations do differ per state, a law has been passed that will apply to all sates and require  a nurse on duty 24 hours  a day in nursing homes. However, in some states this may depend on size of the home "If the House Resolution eventually becomes a law, it won’t require changes at every facility". This is significant to the UK and other countries which continue to question the need for RNs at all in nursing homes, and also indicates that in the USA at least, people have been listened to at congress level and action has been taken (Scrubs 2014). Other factors need to be considered such as does "on duty" actually mean within the home, and the relevance of nurse training to nursing homes, in addition to nature of the patients in nursing homes in the USA.

In the UK, Indeed provides a review of care home companies as rated by eg staff

Span (2014) Federal Law which generates the demise of nurses from nursing homes , "The 1987 federal law intended to reform the country’s nursing homes required a registered nurse on-site only eight hours a day, regardless of the size of the facility." Indeed one nursing home may consist of several building or units on one site. The application of this Law has varied between states. An Act has been proposed to ensure one nurse is present 24 hours  a day. As the author notes, the home could be of any size such as 400 beds.

Many cases of sexual abuse of elderly residents in privatae nursing homes and hospitals are discussed by Nightingale (2014)- within Australia, the UK, and the USA eg Genital Friday club (Australia), rape by a maintenance  man, rape of  a lady in a wheelchair. .

More on USA

Lawyers often display many cases concerning poor care in nursing homes ( 2014). Cases listed here include "A nursing home aide has been indicted for theft of more than $10,000. She was a temporary employee, but managed to steal a patient’s wallet and checkbook during her time of employment. Police check the account and noted $10,000 in forged checks".

"A nurse at a nursing home is dead along with one of her patients after she shot her patient in the chest and then shot herself in the head. A lawsuit has been filed by the family of the man she shot and killed. The family of the patient who died says the nursing home should have dealt with the nurse’s strange behavior to prevent the incident".

"Nursing home neglect is a global issue that reaches beyond the borders of the United States. A nursing home investigation revealed that residents at a nursing home should have been safeguarded against abuse after officials were alerted to various incidents involving patients and neglect or abuse. Investigations did not take place soon enough".

"A question is rising amongst lawmakers and nursing home care advocators alike. The question is, where are the nurses? As lawmakers emphasize the nursing in nursing homes, they are left wondering why there was ever a law passed in 1987 to allow nursing homes to reduce registered nurse staffing to just 8 hours a day. Now they want to reverse the law."

"A group of nursing homes has agreed to a $3.8 million settlement for overbilling Medicare. The nursing homes provided therapy to patients beyond their physical needs and diagnosis. The increased therapy led to the ability to bill Medicare for more money"- profit.

"A nursing home owner has been sentenced for abusing elderly patients at her facility. She had a small nursing home offering care to about ten patients. Patients suffered abuse including physical restraint with hand cuffed to the bed, lack of medical attention, financial exploitation and assault ".

"One state is experiencing challenges rallying support from government leaders. The leaders seem to be more interested in investing their time fundraising for nursing homes. Nursing home care advocates say it should be the opposite.

The advocates would like to see state lawmakers focused on holding nursing home owners accountable for their actions. They would like to see bills passed to increase regulations and facility care and conditions".

Fines for over-prescribing "State legislature is focused on a bill to increase fines and impact the bottom line of nursing homes. The bill addresses the over-prescription of antipsychotic drugs. Nursing homes are abusing the patients by prescribing medications unnecessarily or beyond the actual need and then billing Medicare and Medicaid for the treatment of the patients."

Plus theft from patients, theft of drugs by nurses, drug errors, and there's more. (All nursinghome-neglect as above).

Lundstrom (2014) discusses the huge problem of falsified records which "masks serious conditions and covers up".

after a review of about 150 cases in California (ibid).One particular case is discussed . "Rote charting" is defined as hurriedly filling in boxes identical to the previous day's shift " 9ibid). This occurs in many countries and establishments- not only nursing homes.Evidence has been obtained via cameras in some states of the USA . Some Care assistants explained rote charting is due to "lazy staff" (ibid).


Australia (Knowles 2014) in a care home a resident received respite care for  3 weeks which included  failure to follow care plans, inadequate hydration, inadequate skin care, no medication for 13 days. One problem was said to be short staff; ""There were 71 patients at BUPA, 70 of those were high care and one registered nurse" Mr Watson said, in the BUPA   care home ."BUPA is the biggest private aged care provider in Australia, operating 62 homes around the country (ibid). There is  a call for staff to resident ratios in nursing homes, and improved regulation; "Nurses have told us that a facility will go to all different lengths to ensure that they impress the inspectors. They'll change the menu, for example, so that residents are seen to be getting really great food when in reality the standard Monday to Friday fare may well be baked beans on toast." Mr Watson said (ibid ).

Overington (2014) "Elderly residents have been burnt, drowned and even strangled to death while staying in Australian nursing homes. Others have been deliberately harmed, even killed, by staff.", "In an exclusive investigation, The Weekly this month examines the standard of care in the nation's nursing homes, and asks whether there should be a mandatory staff-to-resident ratio, to protect residents from harm."

Another reports (see below ) of relatives being banned from visiting residents in some care homes (Alberta) (Tremonti 2014). Also occurs in the UK and Australia as discussed. Often this is in response to complaining. In this case the daughter asked to see her mums' "diaper being changed and to check for bedsores". Other cases are described and a group "Public Interests Alberta " are campaigning to change the laws (ibid).

2 nursing homes deaths are described in  2 different nursing homes in Australia; one owned by BUPA (Conolly 2014). Staff are employed with less training, and residents are more dependent on admission (ibid). There is also  a decline in the number of registered nurses working within nursing homes (ibid) and no mandated staff-resident ratios. One case involved falsified records by  a nurse with indications of threats from the owner or manager , in addition to other factors .CCTV footage proved the facts of the first case which involved  a resident falling into  a fountain outdoors. Both homes remain open, and have been asked to review policies and procedures.

Comments to this article are relevant,

"I remember hearing about this where I work (aged care). While we were all appalled, none of us were particular surprised. I've worked in aged care for 8 years now and I've seen our hours cut, our skilled workers cut. I've seen hordes of our workers leaving because honestly? It's just getting to hard to stay. Our profession is the last one too see funding from the government and the first one to see cuts. I think accreditation reflects this well. No wonder these places got 100%. They probably earned that much with what they had to work with! I'll admit, there is no excuse for falsifying records, but I'm not surprised they gave in to it, I've worked with a lot of nurses who know a thing or two about bullying and harassment. I think the people in charge (government) needs to really think about the aging population. Not all of us are going to get their pension when we retire."

"This is what happens, everywhere and always, when the Holy Private Sector is given control over people's lives and welfare. Profit maximisation being their paramount aim, and the cheapest, lowest cost, practitioners always triumphing, the familiar 'race to the bottom' ensues. Staff are kept low paid, imported from overseas if necessary, and their exploitation is steadily increased by ever lower staffing ratios, crap equipment, long shifts and a punitive, judgmental work environment. The quality of food diminishes, stimulation for inmates falls away, they are parked in front of TV all day, drugged to stupefaction to control their behavioural problems and accidents are routinely covered up.
This is how capitalism works. The commodification of everything, even a decent old age, ensures ever greater exploitation, and so-called 'regulatory agencies' here as well as everywhere else, are gutted and neutered as the business owners exercise their hard bought political 'influence'. This is what the Right have worked for diligently for decades-a dog eat dog society, where the Devil Market takes the hindmost, chews 'em up, extracts any value obtainable, then spits 'em out." (ibid).

Strachan (2014) reports "Aged care advocates have called for findings into allegations of neglect at Canberra nursing homes to be made public, claiming the federal government's Aged Care Complaints Scheme is shrouded in secrecy." The Aged Care Act makes it unlawful for information about complaints to be made public (ibid). Does this explain why searches on various websites concerning poor care in Australia yield few results- apart from blogs? Who is this rule protecting? As in the UK and USA, there seems to be difficulty with the complaints system (ibid).

More reports from Australia-(May 2014) "A shocking new report reveals that a startling number of older women are being raped and sexually assaulted in aged care facilities, hospitals and even in their own homes." "Typical of the USA also " (ibid). A lack of forensic evidence is described.

Tozer et al (2012) similar situation in Australia to UK- missing records, wait  along time for tribunals, lack of incident reports, short staffing eg one nurse to 59 patients. The Global Mail will identify aged care establishments that have shortcomings to assist people when selecting one.

 "Assessment teams from the accreditation agency conduct regular scheduled and unannounced visits of homes, and where they find shortcomings, they will often decide to shorten the facility's period of accreditation. In some extreme cases, they will revoke its accreditation altogether. In either case, the agency publishes a decision to vary or revoke the facility's accreditation. Only accredited facilities are eligible to receive government funds" (ibid)."Unlike most healthcare workers in Australia, personal care workers are not subject to formal registration" and there is minimal training (ibid).One case of sexual abuse  by a staff member  was not pursued by police because the lady had dementia and was considered to be an unreliable "witness" (ibid).More evidence of incontinence pads being rationed which has happened in the UK.Regulators very seldom force closure of the nursing home (ibid).It is considered to be in the best interests of the residents to leave them where they are (ibid)."the issues identified in accreditation reports "are not indicative of the industry's performance more broadly" (ibid)- they only consider the home at the time, as with inspections in the UK.Read also the comments.

Medical error Action Group Australia has existed for 18months and details many incidents of poor care within hospitals and nursing homes.

"For over 18 years Medical Error Action Group has monitored nursing homes and it’s a horror story right across the nation.  The failure in care is due to ‘functioning’ on political promises.  Politicians!  It’s not working.  Time to stop ignoring it and fix it!  It’s a disgrace.  You may have someone in your family in need of a nursing home and, if so, God help them because no one else will" (ibid).

Examples of cases; " 2013 SYDNEY:  Aged care nurse, Andrew James DAVIS, who made a dementia patient beg on all fours for a cigarette and treated three other dementia patients with “an attitude of disrespect and disregard”, is still working as a nurse after a professional misconduct finding." (ibid).

"In 2012 MEAG logged 427 breaches in nursing homes, some the same nursing homes we had reported on 10 years earlier.  Nothing had changed.  It worsened " (ibid).

Similar to UK "Accreditation and Standards for nursing homes?  Plenty of accreditation but no standards.  They’re amateurs.  The Accreditation Agency informs the nursing home of its intention to attend, giving them prior warning to “clean up” and “shape up” guaranteeing their accreditation for another year.  If it wasn’t such a abhorrent situation, it would be laughable." (ibid).

"The Australian Government has a problem. Its aged care regulator, the Aged Care Quality Agency has given 95% of nursing homes a perfect score in meeting quality standards. This means 95% of nursing homes are assessed as providing safe care.

But barely a week goes by without the media uncovering stories of abuse, neglect and poor standards in Australian nursing homes. Often these stories are from facilities which have passed quality checks. Rarely is a facility closed because it is found to be unfit to provide care to its vulnerable residents" ( 2014)."Others may nip the problem in the bud by removing quality checks altogether.And this is exactly what the Australian Government is doing. Minister for Social Services Kevin Andrews this month launched the innocuously titled Aged Care Innovation Hub Trial to reward providers which ‘have consistently demonstrated high levels of care’ with reduced quality checks" (ibid). Same is occurring in UK. Who are we protecting? "the Charter of Residents Rights and Responsibilities and the Aged Care Complaints Scheme" (Australia)  is not legally enforceable (ibid).Australia- one unannounced inspection a year on a few of the standards. A re-accreditation check once every 3 years based on all the 44 standards (ibid).This is announced . People are reluctant to complain and blocked by red tape (ibid).

Problems with low wages and a high number of overseas staff are reported in New Zealand rest homes and "geriatric hospitals"  (Collins 2013). There is also a high staff turnover rate which is linked to quality of care (ibid). "The report said 46 per cent of the residential care workforce had no qualifications" (ibid). As in many countries, there is a "call for mandatory per resident staffing  ratio" (ibid). A ratio has been developed but remains voluntary due to concerns about costs, "Its requirements include two carers being on duty at all times in rest homes with 31 to 60 subsidised residents - the typical facility has 56 beds. That equates to between 10.8 and 5.6 caregiver hours per resident per week. But the handbook recommends 14 hours per week for each resident - 12 hours from carers and two hours from registered nurses - and more in hospitals" (ibid).The investigation found (ibid),

" Older people are more likely to end up in residential care in NZ than in any other developed country.
*Care providers say they are funded only to provide "a minimum level of care", almost always without fulltime physiotherapists or occupational therapists.
*The only new care homes opened in the past decade have been in new retirement villages where care costs are effectively subsidised by profits on property investments.
*Providers say state funding is $500 million below the level required to justify building a new stand-alone care home.
*Providers are trying to close the gap partly by charging premiums for en suite bathrooms and other services.

The USA is said to spend  more on administration than 7 other countries  with these costs amounting to 25% of  hospitals spending (Hemmelstein 2014).Scotland and Canada had the lowest figure.Factors that contribute to the high cost in USA include physicians costs, focus one specialist services instead of primary care, and greater use of advanced technology.Further costs include health insurers and providers. Costs were higher in for-profit hospitals than not-for profit or public hospitals (ibid). Of course, the over use of unnecessary treatements by  some  private hospitals, as discussed in this book, has to be considered.

Northern Ireland

A full review of care home and social care focussing on older people,  is to be undertaken in Northern Ireland (Howard 2014) to address "fundamental failings". "This announcement comes after an Independent Review into failings at Cheery Tree House Nursing and Residential Home, in Carrickfergus, showed that “years of cruelty and poor care” had been able to continue in spite of the safeguards in place. The commissioner also admitted there had been lack of protection for whistleblowers" (ibid).Plans are being made to prosecute care home and care service owners. Meanwhile health and social care  complaints have increased by 46%  in the last year   in Northern Ireland  ( 2014).According to the annual report by the Northern Ireland Ombudsman "most of the complaints received by the ombudsman regarding health and social care involved "serious adverse clinical incidents", or the "death of a loved one" (ibid).

Healy (2014) " more than 373 suspected cases of abuse of elderly people in nursing  homes"."Almost 8,700 issues were identified for improvement in nursing homes by the Health Information and Quality Authority last year, according to its annual overview published this morning". (ibid). "Most unsolicited information to HIQA came from concerned relatives ".

Santoro (2006) details examples in Australia care homes and action taken - some of which may well assist the UK. Some of the cases are referred to above. Problems include starving residents, inappropriate treatments, inadequate staffing, neglect and rape of residents. As a consequence many nurses and assistants choose not to work in the sector (ibid). "As a consequence the dregs of society including criminals, psychopaths, sexual predators and every other misfit have been drawn into the system. They can get nominal training in which they display little interest. Morale breaks down. Apathetic staff tolerate the abuse and ridicule of residents by these misfits without complaining. As in the USA elderly ladies were sexually abused and raped. This is clearly much more common than those who should be doing something about the situation will concede. Those nursing homes where morale has been lost and staff are most demoralised are the ones where residents are neglected and misused. They are most at risk of elder abuse rape." (ibid). "Tales of systematic management cover ups and bullying" (ibid).Many of the staff were distressed at what they saw-- some regarded it as fun (ibid).""The biggest money gets poured into their foyers, on chandeliers and nice carpet to impress the families that might want to bring their loved ones in,"(ibid). "if really top quality care was mandated I really don't think it would be profitable anymore " (ibid). The government would not want to intervene due to lack of providers. As discussed (eg wikihospitals) reports of poor care in Australia are harder to find---.



Several reports of poor care in care homes in Wales eg lack of food, dignity "But during the past year, I have also received an increasing amount of correspondence about the quality of life and care of older people living in residential care. This has demonstrated that there are still unacceptable variations in care across Wales, unacceptable examples where older people’s human rights are being ignored "( 2014). Action is  being taken-  Older Peoples' Commissioner Wales is calling for a review. A Dignified Revolution charity run group Wales, does influence policies and challenge poor practice- in addition to highlighting the excellent care that there is.

Again- such issues are not specific to Wales.




There have been several reports of poor care in nursing homes in Sweden (Nightingale 2014) such as forcing  a roll of tape into  a resident's mouth. The  Health Minister in Sweden  is to amend the  law  (Lex Sarah) to enable staff and nurses to report poor conditions and treatment anonymously to authorities . This follows the low reporting of cases due to fear of reprisals ( 2009).

Despite the Lex Sarah law in Sweden, which requires cases of abuse of old people to be reported to authorities, there have been problems with the system. Some authorities have failed to act upon the reports by  failing to  involve the police for example (Genborg 2010). This situation echoes difficulties within the Uk. Whilst in Sweden the article does refer to one home "The officials in charge of the group home Älvgården in Torslanda are receiving strong criticism from the National Board of Health and Welfare (Socialstyrelsen). The residents at the group home have several times been subjected to violence, coercion, and humiliation according to reports from both staff and relatives. " it does indicate possible corruption or major errors.

Westerlund (2011) states "The whole mess started at an old people’s home run by the private company Carema, when management tried to cover up the death of a resident. New, similar stories then came from everywhere. Elderly people have been found forgotten and left in toilets for as much as 12 hours, sleeping on floors, not having their diaper changed for hours when it is “not full”, not having a shower in two weeks, and the examples go on! In several cases, the consequences were dire. In one Carema nursing home, a pensioner, Ruth Jonsson, died of blood poisoning from an infected wound. Another resident has recently died of starvation." "For many people, it has quickly become clear that this is all the result of the privatisation of Swedish public services."(ibid) "These businesses are growing rapidly and are extremely profitable. In Stockholm today, 73% of elderly care services are run by private companies compared with 38% percent in 2006." (ibid)

"A nurse in southern Sweden has been reported for abuse at a senior care centre after she allegedly waved to a colleague with the hand of a recently-dead resident. The nurse was also reportedly neglectful at work, signing that she had given medicine or completed other tasks when in fact she had not". (2014

NursingHomeAbuse Centre 2011 "A Swedish nursing home is reported to have waited five days before reporting to police the alleged sexual nursing home abuse of an Alzheimer's patient by another nursing home resident. The alleged victim’s family were also not immediately informed". "Sexual abuse in nursing homes is not uncommon " (ibid).Of course there are positive reports of care with such as attempts to improve access to IT for residents in nursing homes and more flexible meal times ( Swedish Health Care).

We would welcome updates re this.

There have been many new approaches to care devised to improve care such as Eden project, primary nursing, and the Esther project in Sweden. Such attempts are to be applauded but of course are not perfect. The Esther project in Sweden involves "improved patient flow and coordination of care" with more focus on the individual (Institute For Healthcare Improvement ). Does it really take such money to explore how to care for individuals? Does it really warrant a new ,researched system? Nor is it clear whether or not this applies to private owned establishments within Sweden.


"Rome, October 8 - Carabinieri police placed 13 people under house arrest on Wednesday for allegedly abusing psychiatric patients and the elderly in a nursing home in the Isernia province of southern Italy.The suspects are accused of mistreating, injuring, tying up, beating and neglecting the patients. Among those arrested were the doctor who owns the facility - also the mayor of a local town - a nurse and a number of other health workers. Another 20 people are under investigation" (Redazione 2014).



Very difficult to find information from such countries as China. Lawyers often publish cases;

"Chinese authorities in Hubei province are cracking down on rural nursing homes with increased inspections after an elderly man died from severe nursing home abuse.

A staff member at Taohe Nursing Home allegedly hung the elderly man upside down overnight in freezing temperatures. An autopsy showed that the man died from frost and starvation". (  2011).

There are nursing home abuse lawyers in China indicating a need for them ( ).

"Such is the shortage of elderly care in China's major cities that there are more than 10,000 applicants waiting for the 1,100 beds on offer in the capital's No. 1 Social Welfare Home, according to the Beijing Evening News." (Moore 2013)."Today, around 450,000 elderly in the Chinese capital live apart from their families, but Beijing only has around 215 public nursing homes and 186 private homes, or roughly three beds for every 100 seniors" (ibid). More recent update (Chang 2014) "At this moment, there are 10,000 people hoping to get in" to the same Beijing nursing home.Private investment is massive.



An RCN funded project has commenced regarding the care and development  needs of nurses in nursing homes. No details are available publically at present but it does involve contribution to  a blog This study is so needed but it needs to be considered alongside the issues raised in this book eg who owns the care home? Overseas nurses? Care Staff? Differences between homes?

'Exporting' old people

The practice of sending old people to live in care homes abroad from Germany, continues (Lacey, Foulkes 2014), Seems to be many factors such as cost and inability of relatives to care for the individual. This practice also occurs with other countries (Innes 2014) ; some old people are sent to Thailand from Zurich. Cutltural aspects and education of care assistants or nurses, including procedures and complaints procedures, must be considered. People are also going to nursing homes overseas, particularly to the Philippines, from USA. Most individuals suffer from dementia (Foxnews 2013). There are concerns that the move will unsettle the  patient. Overseas nursing homes are said to have a higher staff level (Foxnews 2013). As this book discusses, training  of staff may not be equivalent to the UK or USA - some staff are not trained (ibid). There may also be issues of fake certificates   and different treatment to the West such as pain control methods or culture,(RCN 2003). There are additional issues (Dimon 2014 ).

Apart from sending  old people abroad, the UK is considering the availability of more sheltered housing for old people. Judging by the present state of affairs regarding NHS or Local Authority funding, this is most likely to be owned by the charity or pivate sector. The Government has" proposed building them on NHS hospital land (Triggle 2014)."."The review also suggested planning rules could be relaxed and discounted prices offered to encourage investment" (ibid).Such relaxation of rules is very concerning, as is this  "In return, care providers could be asked to contribute to council care". Recall previous proposals for hotel run wards - in this book.

Meanwhile in England, social care involving care of people who live at home, is being even more limited ( 2014 a ) "Almost 90% of councils in England no longer offer social care to people whose needs are ranked low to moderate, the Association of Directors of Adult Social Services (Adass) has said." "The government says councils have been given an extra £1.1bn to help protect social care this year" but local councils argue it is not enough.The care system is described as being "in crisis". What are the alternatives? Charities are under enormous pressure, many individuals do not have enough money to pay for adequate care. Will relatives be enforced to care for family  members  even if they themselves are incapable  as is the case in China (see below)? Or if there are no relatives, will neighbours be expected to care for people? Such cut backs are described as being "complicit in murder" ( 2014 b) "A council that is cutting funding to adult social care is "complicit in murder" and could face a legal challenge, campaigners said."Again if the Government does not itself provide care- they are then NOT regarded as being responsible.


Seeking more recent;

USA  "Of the 17,000 nursing homes in the United States, 67 percent are proprietary, just over a quarter are voluntary nonprofit, and the government operates about 7 percent of the homes" (NCHS )

Positive examples

Brooks (2014) describe an example in 3 care homes owned by  a non-profit making organisation  "Since mid-June volunteers from Phakama, an international youth arts organisation, and local students from NewVIc College (Riverlee), Harris Academy (The Manse) and Woodmansterne School (St John’s House) have been visiting residents at the care homes to engage them in workshops, including singing, percussion and song-writing, movement, dance and storytelling, planting, cooking and visual art." This involves young people interacting with old people which is so needed. Of course not all of the residents may want this.

Delivering positive care within care homes is not without debate Dassanayake (2014) describes a situation in  a care home for people suffering from dementia in England. The Fire services ordered artwork to be removed from the corridors as they were regarded as a fire hazard, "Care home manager Linda Britain, 38, said: "At the end of the day we are a home, not an institution or a hospital, and now it feels more like a prison." Such dilemmas are described in (Dimon 2006) and continue to occur. As the article suggests, some compromise may be achieved but  all parties  need involving including residents and relatives.

Brook (2014) explains how a BUPA owned care home in Dundee has WIFI available for residents who wish to use laptopss and I-pads. Of course they may choose to play games . and keep in touch with people with Skype. As Brooks discusses, this may help to keep residents physically and mentally active. there have been earlier reports of residents using the wi for games in care homes. the availability of the Wi-Fi should be standard practice. Although some residents may be unaware of how, or unable to use it.

Brook (2014) describes how  a care home changed its approach towards caring for residents with dementia. Changes included  a painted handrail, hats and coats on coat racks for reminiscence, small seating areas in the corridors, snack boxes for residents who could not sit at the table, drinks left around the home, a new staff uniform and dementia Ambassadors. Of course such changes require staff support and consideration of regulation such as health and safety but they are to be applauded. The use of medication was found to reduce for some residents and they were more sociable. There may well have been affects on staff also? The care home in Scotland is one of several owned by  Meallmore LTD.

Gawande (2014) discusses an example in the USA of animals such as cats being introduced to residents in  a nursing home and how they still met  the regulations "So Thomas said, ‘Let’s try two dogs.’ Halbert said, ‘The code doesn’t allow that.’ Thomas said, ‘Let’s just put it down on paper."  New approaches may be about  challenging the norm and taking a risk . Of course not all individuals will welcome animals. As Gwande suggests nursing homes principally existed for the "health and safety of residents". As this book suggests, does this coincide with expectations of residents or relatives ? Is it fear of litigation that prevents some changes? Numerous other mammals introduced included birds, rabbits and hens. An evaluation indicated the use of prescribed drugs reduced for residents in addition to other aspects . Similar to the earlier study of (Langer and Rodin) concerning giving residents in a nursing home plants to nurture.

Uplands (2014) Amsterdam nursing home run as  a village where "residents live normal lives", "engagement with the community".

Schwartzkopff (2014)  discusses  a nursing home for gay residents "Copenhagen is creating a nursing home with a special focus on serving lesbians, gays, bisexuals and transgender pensioners so they’re not exposed to discrimination in the last years of their lives ". This may be positive for many reasosn including proivacy but some may regard it as segregation. There are such homes in other countries including UK and also for other types of people such as artists.

References (2014) Innovation Hub Threatens to Take aged Care Back to the Dark Ages 22.10 ack Aged Care Crisis/ Catherine Henry twitter

BBC NewsUK (2014) Staff S(acking and Suspensions over Poor Elderly Care 30.4  Ack Gill Ditch twitter ( 2014) NI Health and Social Care Complaints  Up 46% 1.7  a (2014) 'Cuts Forcing English Councils To Limit Social Care' 14.9 b (2014) Derbyshire Countil Council Agrees Cuts To Adult Social Care 18.6

Brook J (2014) Care Home Residents Enjoy Culinary -Themed Summer  Shows Based on Their Own Life Stories

ack carematters twitter

Brook J (2014) Latest Technology Arrives at Dundee Care Home (ack twitter)

Brook J (2014)  Dementia Care led To Reduction in Medication 29.9  (ack CareIndustryNews twitter)

Buchanan M  (2014) Care Home Residents 'Doped' up Survey Finds 30.4 Ack Lisa Bates twitter

Chang GG (2014) Should we Put Granny in  a Nursing Home? 29.9

Collins S (2013) Inside Our Rest Homes : Aged Care's Low Paid Workforce 27.11

Connolly A (2014) Death in a Five Star Nursing Home  21.9 (2014) Care Homes: Older People's Commissioner Says the Minimum is Not Good Enough For The Elderly 29.1

Dassanayake D (2014) Dementia Sufferers Despair As Care Home Ordered To Remove Art Because It is  A 'Fire Risk' 31.7 ack twitter

Dimon C (2014) Hasta La Vista Gran

Foxnews (2013) More Alzheimer's Patients Facing Care Far Overseas 30.12

Gawande A (2014) Can Life in a Nursing Home Be Made Uplifting and purposeful? 4.10 (ack ageing and disabled twitter)

Genborg L (1010) Violence and Coercion At Group Home 26.11

Healy A (2014) HIQA reports 373 Cases Abuse ofg Nursing Home Residents 6.5‎

Hemmelstein DU (2014) A Comparison Of Hospital Administrative Costs In Eight Nations : U.S. Costs Exceed All Others By Far The Commonwealth Fund 8.9 commonwealthfund,org (ackGerry twitter)

Howard R (2014) Care Home and Social Care Regulation in Northern Ireland Subject to Full Review 11.8

Innes (2014 ) The Families Sending Relatives to Cheaper Nursing Homes in Thailand :Care is 'Cheaper and often Better in Asia', They Say Mailonline 9.1

Institute For  Healthcare Improvement (nd) Improving The Patient Flow: The Healthcare Project in Sweden


Knowles L (2014) Death of Beryl Knowles After Stay at Kempsey Nursing Home sparks Calls for Aged Care   Accreditation Overhaul 16.6  (ack AgedCareReviews twitter)

Lacey A, Foulkes I (2014) Exporting Grandma to Care Homes Abroad  BBCnews 5.1 (ack R Cantwell)

Langer E, Rodin J (1976) The Effects of Choice and Enhanced Personal responsibility For The Aged : A Field Experiment in an Institutional Setting

Lundstrom M (2014) Woman's Death Raises Questions about Nursing home Hospital Records 10.8

May J (2014) Shocking number of Elderly People being Abused in Aged care homes  7.7 ack Delia Scales Wikihospitals

Moore M (2013) China's Ageing Population: 100 - year waiting List for Beijing Nursing Home 16.1

NCHS Press Room (2000) U.S . Nursing Homes Profiled in a New Report  NCHS/CDC Public Affairs, (301) 458-4800 

Nightingale L (2014) International Isses- Privatisation and Care Homes

Nurse Uncut (2014) Every Nursing Home Has an RN- But For How Much Longer? (28.5)

Nurse Uncut (2014) RN'S in Nursing homes - A Reprieve 23.6

Overington C (2014) Are Our Loved Ones Safe in Nursing Homes? 31.7 ack aussieagedcare twitter

Redazione ANSA (2014) Abuse Uncovered At Southern Nursing Home of Horror  8.10

Santoro S (2006)

Schwartzkopff F (2014) Gay Rights in Denmark Rake Next Step with Rainbow Nursing Homes  12.11

Scrubs (2014) New Law  would Require RNs at All Nursing Homes 24/7 9.11 (ackAnn Ditch twitter)

Span P (2014) Where Are The Nurses? 13.8 (ack NursingScience Watch twitter)

Strachan J (2014) Aged Care Complaints List Kept Secret 27.9 (ack Delia Scales wikihospitals) (2009) Minister To Change & rdquo;Lex Sarak & rdquo 19.4

Swedish Health Care (nd)

Tozer J, Coutts S, Blumer C (2012) Inside Australia's Nursing Homes :A New Online Tool  8.3 ack Delia Scales Wikihospitals

Tremonti  AM (2014) Why are family Members Being Banned from Visiting Their Family members in Care Homes? 11.3

Triggle N (2014) Build Homes For Elderly On NHS Land, Says MP 3.9.14

Uplands J (2014 ) The Dutch Village where Everyone has Dementia 14.1 ack L Green twitter

Westerlund Per-Ake (2011) Scandals in Privatised Old People's Homes 2.12


Chapter 4 Hospitals

Cases of staff discouraged from whistleblowing in hospitals remain ( 2014). Examples given at the NHS hospital in Wales,  include nurses shouting at patients, missing referrals, patients being got up at 6am. The nurse comments that such examples do not only arise on elderly care wards. These are not isolated issues . Such reports further indicate the important of speaking out.

In a study of several countries (The  Commonwealth Fund 2014), USA was found to rank last regarding healthcare outcomes of which patient centred  care was  a factor. This included surveys of patients and physicians. The UK was ranked first. Factors include who owned the hospitals,and what fields of care were surveyed - acute areas or nursing homes.Also as this book discusses, care differs  between USA  state and in Australia,  according to regulations and quality.

Naish (2012) discusses the dilemma of who is responsible when poor care is received in a private owned hospital to which NHS patients have been sent by the NHS.Naish describes the case of Celia Corlett who had  a badly  done hip replacement by surgeons brought over from South Africa by Netcare; "‘They made a catastrophe of my operation,’ she says".Remember there are differences between standards, training,  and cultural attitudes. Does the NHS inform patients when they are sent to private hospitals that there are differences between standards and complaints procedures when compared to the NHS? "she employed a specialist lawyer — Laurence Vick, a leading medical negligence advocate. Mrs Collett’s case was settled out of court and she accepted substantial damages " (ibid).A single "rogue surgeon" was blamed by Netcare. Remember the high number of fake certificates from overseas. Did this apply in this situation? Naish states "At present, there are no umbrella systems in place to monitor the quality of care across private hospitals." which supports findings in this book.There is as Naish states, a greater number of NHS patients being sent to private care hospitals.The question is - why are these problems not addressed by the government and regulatory bodies? This is one question this work attempted to analyse.

Pollock (2014) "We have learned this week that the NHS is footing the bill for dozens of people left damaged by eye operations provided by private healthcare operations". As Pollock Describes, according to the Independent Sector Treatment Centre  Programme,£5bn have been used for this purpose since 2003- to pay for services in for-profit private healthcare.Of course consultants may as Pollock states "moonlight" between NHS and private care, and nurse training is paid for by tax payers (apart from some exceptions of students from overseas)."The NHS also takes on the legal liability when patients sue the facility" (ibid)."However, the multimillion-pound contracts which have been awarded to companies such as Care UK and Ramsey Health Care UK are confidential and rarely audited" (ibid), nor do we know again, who the investors are thus there may well be conflicts of political interest. If work is contracted, it may be paid for by the NHS but not done (ibid).Pollock describes how this approach affects the treatment of patients' eyes including adverse incidents and more travel.This leaves some NHS services underused and affects the training of surgeons  (ibid)." There are now a number of high-profile deaths in the private sector where the NHS has had to pay out compensation to the families, rather than expose the truth about the policy" (ibid).This is hastening privatisation- but for what?

There are many other patients who are treated within the private sector in the UK , paid for by the NHS including mentally ill patients or old people.

"Some of Britain's leading hospitals stand accused of exploiting the coalition's controversial lifting of the cap on the number of private patients they can treat to increase their income as part of a "creeping privatisation" of the NHS." (Watt 2014). The cap for privatisation was increased within FT's (See FTs). "The figures, released to the shadow minister for London, Gareth Thomas, showed an increase in private patient income at:

• University College Hospital Trust in London by 39.63% – from £7.3m in 2010‑11 to £10.3m in 2013‑14.

• Royal Brompton Hospital Trust in London by 37.7% – from £24.3m to £33.6m.

• Moorfields Eye Hospital in London by 31.84% – from £16.1m to £21.3m.

• Papworth Hospital Trust in the South Cambridgeshire constituency of the former health secretary Andrew Lansley by 29.9% – from £4.9m to £6.4m.

• Royal Surrey County Hospital Trust, which serves the South West Surrey constituency of the health secretary, Jeremy Hunt, by 25.6% – from £3.6m to £4.6m.

• Chelsea and Westminster Hospital Trust in London by 20.99% – from £10.7m to £13m " (Watt 2014).

There is  a call for 'private hospitals to provide more safety data' (Dreaper 2014).At present as discussed in this book, private hospitals have different complaints procedure and do not provide the same data as the NHS. Yet "Private hospitals now receive 28% of their income from treating NHS patients" (Dreaper 2014).Data needed includes death rates and complications such as infections (ibid). It seems data kept by the CQC needs  to  be more explanatory than "800 patients died unexpectedly " (ibid). This failure to keep data does not assist relatives who are desperate to uncover reasons , nor does it assist the profession to make changes if required. The CHPI report " recommends that private hospitals report on their performance in the same way as NHS providers - with data such as infection rates made available on the NHS Choices website, and monitored by the Health and Social Care Information Centre" (ibid). Such  a web site for the private sector is an aim of Delia Scales in Australia (wikihospitals) as discussed. The report also recommends  a comparable complaints procedure.

CHPI = Centre For Health and Public Interest

Leys and Toft (2014) report concerns about private hospitals including unexpected deaths and inadequate record keeping .They note additional problems such as consultants working "of-site". Few private hospitals "have facilities for high-risk patients". Yet 27.5% of private hospital patients in 2012 were NHS funded (ibid).The report notes (as we found) there is very little available literature on private healthcare in the UK.Recommendations include provate providers  must report safety incidents and mortality data to the same requirements as the NHS,remit of PHSO should cover private sector, patients should be aware of risk factors in private sector compared to NHS (ibid).

This issue is also relevant to Australia- see below Delia Scales.e also

Meanwhile these findings are disputed by  an author with connections to the Independent Healthcare Advisory Setrvice (Booth 2014).


Fiona Booth is chief executive of  the  independent healthcare advisory Service for charity and private owned hospitals  who are members. There is also a Scottish and a Welsh branch.

 "AIHO represents a broad range of private and charitable healthcare organisations which provide services into the NHS and directly to insured and self-paying patients.”

 The Independent Sector Complaints Adjudication Service  investigates complaints of charity or private hospitals who are members of the IHAS or members of the ISCAS

 They will take one of 3 actions- local resolution/complaint review/independent external adjudication .

These actions need further explanation- especially independent external adjudication.

An annual report is available

Yes of course there is excellent care in all fields , regardless of who owns it, but it should not be used to whitewash the fact that poor care does occur and needs addressing.

"The public need to know that our NHS is being privatised, not through the back door, but very blatantly through the front" (Taylor 2014) describing how the process has affected the delivery of HIV services and sexual health. As Taylor discusses, the private sector are more concerned about money than quality. There may be some exceptions. "The private sector does not want to be concerned with the HIV services (ibid), as Taylor states they "cherry pick" the services.Who cares enough to intervene? An international issue.

Meanwhile Jeremy Hunt announces that £2.5bn is spent on dealing with medical mistreatment in the NHS,  a year .( 2014)_Such errors or negligence,   include medication, infections, and pressure sores. These are only the ones they know about- errors occur in any area of care regardless of who owns it. Indeed staff may be unaware that they have done an error.It is not identified whether or not these errors included patients treated within private hospitals, paid for by the NHS.

Hughes (2014) extends the report regarding botched eye operations done within the private sector for NHS patients."The firm behind the “painful” and “rushed” eye operations is backed by a leading Tory donor who hangs out with Iain Duncan Smith" (ibid)- see the links as identified by Lenin Nightingale and others."But last month the BBC got a copy under freedom of information rules. The report found that only 25 of the 62 patients had “normal” recoveries" (ibid)- the company is Vanguard."Some of the patients are suing for damages — represented by Laurence Vick, an experienced medical negligence lawyer from Michelmores solicitors But as Vick pointed out, it isn’t clear who will pay any final settlement — Vanguard or the NHS.". - precisely. As this book discusses private equity trusts evade responsibility."Rory Brooks has given the Tories £276,000 since 2008. He founded and leads the venture capital company MML Capital" (ibid) - which invests heavily in Vanguard.Hughes discusses another affect- the avoidance of tax paid by the NHS.

A figure- thanks to FOI, of taxpayers money spent placing NHS patients in private hospitals in Kent "The county’s NHS mental health trust spent more than £5 million on private hospitals last year due to a shortage of beds for patients.A Freedom of Information request shows 356 patients in Kent were placed into private care over just 12 months because beds could not be found..The patients, detained under the Mental Health Act, were sent to “places of safety” up and down the country at a cost of £5,671,000 to the taxpayer" (Pragnell 2014). Not to mention possible lack of staff or greater use of overseas staff as this book discusses.



Marsden et al (2014) Daily Mail campaign, but some argue it is against Wales which is labour run as there are incidents similar in all UK regions  (Gralton 2014). "The Daily Mail has uncovered appalling cases of patients dying while on waiting lists or being forced to move to England for life-saving treatment"( Marsden et al). "Today’s survey, commissioned by the Welsh Conservatives, found that a third of people with recent experience of hospital treatment had encountered problems and nearly one in five felt their concerns were not taken seriously" (ibid).

Individual cases are discussed above and within this book.

"Inquiry demanded into NHS Wales after survey slams patient service . Health campaigners, alongside The Daily Mail newspaper, are demanding a full-scale inquiry into the Welsh NHS amid allegations of severe patient neglect running through the entire service"  ( 2014). There is said to be  a "sense of denial in Wales" unlike in England following the Francis report. However, as this book indicates, there is an international sense of denial." assists a large number of members of the public from Wales who have used the NHS there and have made a wide variety of claims regarding medical mistreatment, predominately relating to A&E, misdiagnosis and delay and relating to elderly care" (ibid). Cases include  delayed ambulances, missing or falsified records, and denial of food and water to old people with lack of attention to toilet needs (ibid).




Donnelly (2014) states "More than 50 deaths of mothers and babies at a scandal-hit hospital are under investigation by an independent inquiry."  Again this is a FT hospital which is run without government involvement and is semi-private. "Regulators had  attempted a cover-up". The deaths occurred between 2004-2013."The investigation was ordered by ministers last year after a long campaign by a bereaved father, James Titcombe, whose newborn son died from a simple infection which could have been treated with antibiotics". The issue remains- was the CQC under orders from politicians to withhold negative findings  as Donnelly proposes , Cases of CQC inspectors being pressurised to alter reports have been outlined in this book, and the existence of  this issue is supported by Donnelly .


The USA is said to spend  more on administration than 7 other countries  with these costs amounting to 25% of  hospitals spending (Himmelstein 2014).Scotland and Canada had the lowest figure.Factors that contribute to the high cost in USA include physicians costs, focus one specialist services instead of primary care, and greater use of advanced technology.Further costs include health insurers and providers. Costs were higher in for-profit hospitals than not-for profit or public hospitals (ibid). Of course, the over use of unnecessary treatments by  some  private hospitals, as discussed in this book, has to be considered


One third of USA hospitals may close or deliver healthcare in some other way according to Houle and Fleece 2012. This is due to the high cost of care . Also " statistically speaking hospitals are just about the most dangerous places to be in the United States"- concerning medical errors. Waiting times in casualty are approximately 4 hours. American hospitals are about to enter the open competitive market which means profit.

Why the relevance for the UK or other countries? The Uk often follows USA some years later. An essential factor within privatisation is profit- it has to be.Healthcare and other essential services ought not to be privatised or we risk unequal provision of service if any, for the poor and the wealthy. Could that be the issue? Politically there are the deserving rich and non-deserving poor.

Wikihospitals (2014) reports of a new book (Makary 2012) regarding hospital errors in USA  and statistics that are not publically available.As the author states, "It is estimated that 18,000 people die in Australian hospital errors every year and 50,000 suffer a permanent injury".Yet "When New York introduced mandatory reporting of death rates from bypass surgery, hospitals scrambled to improve, and their death rates fell by 41% in four years." Such information is kept out of mainstream news in all countries.

In Australia, the site patientopinion "is modelled on UK initiatives-- following Mid Staffordshire". Public pressure and international links can make  a difference. The site is run by  a not-for profit charity and allows people to comment on health services.

A psychiatric hospital at Oregon (USA) has been under investigation (Zheng 2014). Several patients were sexually abused by nursing aides 1989-1994 as discovered in a 2004 investigation of another case involving  a RN."Incidents are less frequent these days, in part because of numerous security cameras installed in the new hospital campus that opened in 2012" (ibid). There have been other incidents at the same hospital (Oregonian 2008) including withholding of medication by  a doctor and  a whistle-blower who was forced out. Oregon state hospital is state owned. Is it possible that the more privatisation-  the less focus on state owned and the more regard of people "who cannot afford private " as second rate? Note also the patients who are mentally ill, are one of the most vulnerable types of people.Of course one has to consider also what is happening within private or charity owned establishments- reports are not easy to find in any country.

In California  KQED, KPCC in Los Angeles and have teamed up to create  a data base to compare costs in healthcare  within California (State of Health 2014). This data base is funded by businesses and is an example of one initiative that may assist patients and families. Several links for quality webs sites are also listed such as

There are also other groups who rate hospitals

As mentioned in one of the end comments- one individual has established similar for different areas of the USA

Lauer (2013 )cites Makary "One in four hospital patients is the victim of a medical mistake. Thirty to 40 percent of our healthcare dollars pays for fraudulent or unnecessary care. Ten to 15 percent of patients are not given all their options for care. And a surgeon operates on the wrong body part 40 times each week. A Harvard study published in The New England Journal of Medicine in 2010 found that as many as 25 percent of all patients are harmed by medical mistakes. These mistakes are the fifth leading cause of death in the nation." "a code of silence against reporting physicians' mistakes " (ibid)."The message is simple: When hospitals have to provide solid outcomes data, their performance improves". This is also also a proposal in the UK (bbcnews 2014 ). "installing cameras at hand-washing stations in North Shore University Hospital on Long Island improved hand-washing compliance by more than 90 % (ibid). "The book says young physicians, medical schools and medical societies seem less willing to protect their poorly performing peers, and some hospitals have even taken a pledge of transparency." (ibid). . Students are  a great hope also in nursing- but as this book indicates, courses and lecturers differ between universities.


The differences between private and state owned hospitals are highlighted by Wikihospitals (2014), " I discovered that there were dramatically different standards of care between many public and private hospitals for exactly the same treatments." Delia Scales speaks of a lack of training, staff, and the over-use of expensive treatments in private owned hospitals ,based on Delia's experiences as nurse and patient and talking to others.This is supported by the findings in this book and occurs within USA and the UK. Delia Scales does have plans to create an app for patients to access information quickly about best practice guidelines and  a 'Trip Advisor' website for rating and discussing hospitals.

Some private hospitals in Australia are so bad that health insurers do not want to cover them (news.com2013). This is based on 4 years of data on 600 hospitals. "The insurers have decided not to publish the research for fear of being sued by sub-standard hospitals" (ibid). As the article argues, the public have a right to know."Private hospitals perform about 2 thirds of elective surgery in Australia " (ibid). Some of the factors included infections and having to redo operations. There has been a battle to make the research public at all.

As in the UK, reports anda data are not always published by the private sector in Australia (Scales 2014), "Dr Armitage’s four-year report into infection rates in private hospitals (was) withheld from publication, citing ‘privacy laws.’. Scales also notes differences between private owned and state owned hospitals such not as weighing patients undergoing chemotherapy  and lack of specific nurse training in some private hospitals ,An estimated 18000 people a year die in Australia due to hospital errors (ibid) but "there is no systematic  collection and linking of hospital data". Delia Scales ends poignantly, "The moral of this story? Don’t forget where nursing came from. Years of tough battles to introduce reform into a reactionary and very powerful industry. And don’t forget the lessons of the Sanitation Movement. Careful observation. Diligent collection of statistics. And the courage to publish the results. No matter who they upset."

 "the Australian health and aged care systems are fundamentally and fatally flawed with no solution in sight." (Dr Mykyata in Andreyev 2014).He describes problems concerning residential and nursing care which depend on the level of care needed. Patients in residential care- are outside the healthcare system. This is similar to the UK. Therefore there is  a reliance on hospital admissions from residential care environments. There are visiting GPs to residential care- similar to the UK. Of course as Dr Mykyata describes, there are regional differences between Australia and the UK- such as isolated  bush areas. "Residential aged care is often plagued by accusations of poor clinical decisions and poor management, particularly around behavioural problems, pain management and palliative care.(Mykyta 2014).

Dr Mykyta calls for Doctors to make the decisions- not politicians, specialist geriatric services and rehabilitation.

This must be considered regarding the overall political emphasis of neoliberalism and privatisation as discussed within this book.

In Australia, many patients remain in casualty as there are not any empty beds due to older people remaining on wards (Sexton 2014). An organisation "VITA" which is non- profit and govt funded, has been established to set up a ward specifically for older petients, run like a hotel and focussing on quality of life. This issue also exists within the UK. In Australia the patients are expected to be on this ward for  a short time only, and it may prevent some from going to residential care homes by rehabilitating the individuals.

Belardi (2014) reports that in Australia  "Community aged care workers  are being upskilled in palliative care as part of an integrated approach to supporting more people to die at home".Carers may remain with the patient while the family sleep in the next room to give them  a break. .200 carers have so far had this training (ibid).This is funded by NSW Government but delivered by private companies. "Most Australians say they want to be cared for and die at home. Yet across Australia only 16 per cent of people achieve this outcome, and more than half die in acute care hospitals " (ibid) echoing issues in other countries. "As part of the program, generalist community workers receive training in palliative and supportive care through the Learning and Research Centre at Greenwich Hospital under international palliative care expert Professor Rod Macleod and specialist clinical nurse consultants" ( bid). "For the first time providers of aged care services in Australia will have access to a dedicated national telephone support line for advance care planning (ACP) and specialist palliative care advice" (ibid).

This is part of  a Commonwealth Government funded project. Many cares would welcome this service - in many countries. Australia seems to have obtained the funding for it and be able to provide the training. Other carers for other patients such as individuals suffering from mental illness or dementia, may also welcome such a service.

45% of the 1347 hospitals in Australia are now privately owned ( 2014). Of these 319 are day hospitals and 282 are overnight hospitals (ibid). Some private hospitals voluntarily report safety and quality of care data- they are not legally required to do so (ibid).This is similar to the situation in the UK. 2 thirds of elective surgery ion Australia   is provided in private hospitals (ibid). As discussed, information about care in Australian hospitals or nursing homes, is usually blocked from publication- see also 4bitnews.


Fess for healthcare in Canada, are very expensive- paid via public health insurance."A typical Canadian family with two parents and two kids will pay up to $11,786 for public health care insurance this year, according to a new study from the conservative think tank Fraser Institute" (Lueng 2014). Some services are privately owned such as hospitals and nursing homes.

Despite this, Serna (2014) explains you are more likely to see the doctor if you are rich than if you are poor, even though the Government pays the bills. This was found after researchers posed as patients who rang for appointments . "Overall, the callers were 50% more likely to be offered an appointment when they posed as bankers than when they posed as welfare recipients" (ibid)."Researchers randomly selected the 375 offices out 3,367 family physician and general practitioners in Toronto. Physicians excluded from the study included specialized practices, doctors with disciplinary records and offices that don't offer appointments because they accept only “walk-in” patients" (ibid)."The study did find that people posing as sick, regardless of how they described their economic status, were more likely to get appointments than were callers posing as healthy" (ibid). Questions of discrimination are raised.

Hildebrandt (2013) describes the situation in Canada stating "nearly 25% of Canadian nurses wouldn't recommend their hospital". This was based on respondents from nursing associations and unions. Major problems were said to be burnout and staff shortages.Yet nobody from a class of125 graduating nurses, could get a job (ibid). Staff are often not replaced when off sick.88% of the respondents did say patient safety was acceptable.40% said action was not taken when errors occurred, and they could not deliver the standard of care that they wanted to (ibid).36% said supplies, materials, and equipment were lacking.Nearly 6% said basic hygiene items such as gloves were lacking."After you fix the nursing, you will fix the rest " (president of Canadian Federation of  Nurses Unions ibid).


Appalling effects on healthcare (and education) are discussed within Sweden ( Olsson 2013) as consequences of neoliberalism and privatisation . "One fifth of elderly care ,residential,or home help is in private hands (ibid). The article again describes the examples given earlier regarding Sweden and care homes."Many scandals have been exposed" (ibid).Staffing levels are lower in the private sector than public sector and profit is distributed to shareholders (ibid).Similar to the UK, benefits have been cut and unions weakened. All part of the process.


News from China (Sudworth 2014), people are so dissatisfied with care in China they are attacking members of healthcare staff. "A nurse left paralysed in Nanjing, a doctor with his throat slashed in Hebei and another beaten to death with a pipe in Heilongjiang" (ibid). "Chinese policymakers are trying to reform the system by widening access and expanding social insurance cover" (ibid).There are claims of expensive fees, malpractice, and corruption (ibid).

There  have been assaults on  NHS staff in the UK  by patients (Smith 2013),"Attacks by patients in these circumstances (waiting times/short staff)  rose from 39,770 in 2010/11 to 46,265 in 2011/12, an increase of more than 16 per cent". This needs more research- are the attacks different  in nature and cause to within China? Do such attacks occur in other countries particularly USA and Australia? How many attacks of staff occur within the private or charity sector including care homes.


As from many countries, information from Russia is not readily available and is hard to find. This report from HRW (2014 ) states "Nearly 30 percent of all children with disabilities in Russia live in state orphanages where they may face violence and neglect. Russia should stop abuse of children with disabilities in state care, and make it a priority to provide support for children with disabilities to live with their families or in other family settings, rather than in institutions"."Some children interviewed by Human Rights Watch said that orphanage staff beat them, injected them with sedatives, and sent them to psychiatric hospitals for days or weeks at a time to control or punish them." "The report is based on over 200 interviews with children, family members, advocates, and orphanage staff, and visits to 10 state orphanages across Russia " (ibid).Staff sometimes  "discouraged visits from family members". Possible contributory factors include lack of resources,lack of staff training, and lack of staff (ibid).parents were often pressurised to put their disabled children in orphanages, decisions unaided by the lack of community support. Many of the children are left in "cribs" or tied down with rags (ibid).The Russian government "has recognised the need to reduce institutionalisation of children " (ibid).


Could prison be regarded as a place in which to hide social problems when considering 28% of people in Australian prison are Aborigines? › Aboriginal cultureLaw & justice 2014. Further, war veterans in USA are imprisoned for deviating against politicians by telling the truth about war (Nightingale 2014). Politicalears (2014) in Icke, present an article regarding people who are imprisoned for talking against Obama. There is also the fact that mental illness may be exacerbated or developed, when in prison. Australia's National Health Commissioner (2013) described prisons as a "dumping ground for the mentally ill" who include more than half the inmates ( .Historically between UK, USA, Australia there are similar issues with closure of asylums and inadequate  availability of  care in the community.Mentally ill patients are  ten times more likely in USA to be  in prison than in hospital (Novak 2014). Could this be indicative of the lack of services (as in UK). "In 2012, prisons and jails housed 365,000 people suffering from chronic psychotic disorders such as schizophrenia and bipolar disorder, while the number of such patients at state medical facilities was just 35,000" (Novak)."prison administrators and guards lack the resources, training, or legal basis to provide such prisoners with adequate treatment" (ibid)."Officials and health care workers in prisons are often legally barred from treating mentally ill inmates with psychiatric medications or sedatives (ibid). As Novak discusses, care is incompatible with profit making. In the UK (Panorama 2014) discusses scenes witnessed  by 2 reporters,in USA prisons of the treatment of mentally ill prisoners, "The programme reveals that more than a million mentally troubled Americans are imprisoned and may be chained to beds, sprayed with pepper spray and kept in isolation indefinitely." Andersson (2014) explains "More than one million people with mental health problems are in US jails" and more than 80 of them have died since 2003. There is said to be  a lack of appropriate facilities to care for people suffering from mental illness.  The US Department of Justice is investigating. Yet why did this again need Panorama to highlight the situation? Again, is this reflective of the neoliberal society in which we live? In the UK many prisoners are also mentally ill and receive inadequate care (Prison Reform Trust 2014). An issue raised by this book, is who owns the prisons? Many are now privately owned.

More reports of high number of suicides in UK prisons-  BBCnews (2014), RINF (2014)

MacNicoll (2014) "People in mental health crisis who have been detained by police officers are being turned away from NHS units due to them being full to capacity or understaffed, the Care Quality Commission has found." "In 2012-13, a total of 21,814 people were detained by police under section 136 of the Mental Health Act. The CQC said that 7,761 cases ended up in police cells rather than health-based places of safety. The review also found a direct link between place of safety provision and the use of police cells" (ibid).As indicated above, there is inadequate mental health care for prisoners.

So links to social attitudes, politics, and money.According to RINF (2014) "Since January alone, 44 people took their own lives in British prisons, while incidents related to self-harm reached 23,478 this year – an increase of 750 since 2012-13." (2014) "Thousands of inmates are sexually assaulted in prisons in England and Wales each year, research suggests." "But the commission's paper suggests sexual abuse in prisons is a hidden problem that is largely unreported." The study concerned male prisoners "some prisoners were coerced into sex to settle debts, while others used it as a way of paying for drugs" (ibid).The level of sexual assaults is "similar to that in the USA" (ibid).There is also said to be a lack of approved mental health professionals and Doctors thus delaying admission to mental health units (ibid).

More UK evidence (Kotecha 2014) "Too many people are being jailed unnecessarily, the head of a review into prison suicides has said." This links to Lenin Nightingale' points (2014) regarding profit and private prison and factory jobs. A high number of suicides is again described (Kotecha) with staff shortages. The point is made that if  people  were not inappropriately imprisoned more adequate rehabilitation could be provided.

Australia Georgatas (2014) explains many Australians especially indigenous are sent to jail for non-payment of fines. Some of these fines refer to $20 parking fines. This is also the case in some states of the USA (Nightingale 2014)- especially when people are unable to pay for their own probation.This could well be linked to privatisation.


In Canada the healthcare of prisoners is not always being addressed (Barrett 2014) " The review process for deaths in Canadian prisons is failing to address systemic misdiagnoses, poor continuity of care and lack of follow up for sick inmates, Canada’s prison watchdog has found"."In some cases, lack of proper care appears to have contributed directly to inmate deaths. The report cited one who was treated for pneumonia three times over two years, despite multiple X-rays showing a mass in his chest and blood work suggesting a more serious condition. He was eventually diagnosed with lung cancer by an outside hospital, but the tumour had become inoperable" (ibid).Threats to public health are identified "With the vast majority of prisoners destined to be relased into the community, any untreated health issues — such as HIV, hepatitis and tuberculosis — can then be introduced to the general population" (bid).


Seeking USA/Australian perspectives


There have been many debates regarding euthanasia in many countries, for many years. A former euthanasia supporter, Thoe Boer (Doughty 2014)  now considers whether or not it was the correct approach as more people with mental illness or dementia are subject to euthanasia, “His native Netherlands, where euthanasia has been legal since 2002, has seen deaths double in just six years and this year’s total may reach a record 6,000.”
 In the UK the Liverpool Care Pathway  was ceased due to misuse whereby care could be withdrawn  (Chorley 2013).

 In one hospital in the UK there is now  a mass inquiry extending between  1988 and 2000 regarding around 100  deaths of old people due to the routine use of morphine. (Boyle 2014). “A police review into a number of the deaths did not provide enough evidence for prosecution, however and earlier review of clinical practice at the hospital criticised the routine use of opiates while treating elderly patients.” 
The danger is that care is unavailable to the more vulnerable, cost of actual care, and attitudes of others towards the patient, including beliefs. Yet some patients  choose this option due to their suffering and others consider it to be  a compassionate approach..

In Sully (2014) Archbishop of Canterbury Justine Welby  argues "It would be very naive to think that many of the elderly people who are neglected and abused each year, as well as many severely disabled people would not be put under pressure to end their lives if assisted suicide were permitted by law,"

In Australia assisted dying is  still under debate (Syme2014) "under the law reform proposed by most societies, only terminally ill patients of sound mind would have access to information and medication.

Mental Health

As discussed in this book, people who are mentally ill, and other vulnerable people, have been misunderstood or overlooked throughout history due to many factors such as stigma or politics. Novak (2014) describes the situation in USA where inadequate treatment is given to people who suffer from severe mental disorders. Many individuals who are mentally ill, end up in emergency rooms  , jails or on the streets. This is supported by Nightingale (2014)- the majority of people within jails in the USA and UK are mentally ill before they enter jail. "According to statistics released by the National Alliance on Mental Illness (NAMI), roughly one in every four adult Americans experiences a mental illness in any given year" (Novak 2014). "Suicide now claims the lives of an estimated 38,000 Americans a year" (ibid). Novak explains that treatment is not usually started early enough ,people who are mentally ill are arrested for minor offences, and they are imprisoned without adequate medical treatment . People who are mentally ill are often abused in US prisons (ibid).Again, similar to the UK- see prisons above."In fact, mental health services are often the first state programs to be stripped away" (ibid)- this is occurring in the UK (Lintern 2014).Lintern discusses serious financial cuts within the field of mental health in addition to the huge reduction of hospital beds and nurses , which does vary between districts. The cuts  " included day treatment centres, 72 hour intensive assessments and investment in new facilities and improved community based teams" (ibid).This will explain why some trusts send mentally ill patients to private care establishments. Again, the most vulnerable people are the hardest hit- old people, people with learning difficulties, and the mentally ill. They who politicians deem to be "non-contributors". Will there eventually be no such services?

For many years there have been concerns about suicides in psychiatric hospitals within several countries including USA, UK, and China  ( eg Gordon 2002,Li et al 2008).The figure is said to be increasing (Gordon 2002) including hanging or self-strangulation."Of the 206 deaths  (of patients detained in England and Wales) , 169 (82%) were in general psychiatric hospitals, 11 (5%) being in intensive care units" .Gordon (2002) highlights  a number of relevant factors such as first week of hospitalization, patients who are on leave from the hospital,. ward design or nurses shortages. "Almost one-quarter of the patients who died were on special observation, 3% being on constant observation" which brings into question the practice  of observation. Of relevance both articles recommend the assessment of risk factors such as gender and condition which are used in the UK  .

Champion (2013) writes about " a series of suicides at  a psychiatric hospital in Leicester,"There have been 10 suicides since 2010 at the Bradgate Unit. Inquests have highlighted repeated failings by staff ". A patient who was under section at this hospital, was able to get out of the hospital and take her own life (ibid).Questions were raised about assessment and staffing levels. "Across the UK, there are on average 160 in-patient suicides a year" (ibid)."Unlike deaths in prison or police custody, fatalities in psychiatric units are not reviewed from the start by a fully independent investigator " (ibid).The CQC "it accepts that it was wrong to say the hospital was compliant with national standards when in fact it was still not safe" (ibid).There is  a call for fully independent investigations (Coles  in Champion) but again, what is independent?

B (2010) details severe neglect and ill-treatment of people who are mentally ill in Romania . One reason was said to be because healthcare in Romania was "heading for bankruptcy". "In some counties in Romania, one psychiatrist serves a population of 320,000"."In this system, some councils bundle schizophrenics, beggars, the handicapped and sufferers form Alzheimer’s into one institution - and feed them on the same drugs to shut them up" (ibid)."Many institutions - with some notable exceptions - are often cut off from the community. It has been common practice for three patients to share two beds pushed together, while women and men often bunk and shower with one another. Although some local authorities do understand the need to integrate users in the community, many councils refuse to give up public buildings for the care of the mentally ill " (ibid)."Decades on from being abused by a more sinister regime, these voices must not be discounted again as the ramblings of the insane - for they understand how their own health problems are as severe and as absurd as those of the system which is supposed to care for them " (ibid).More recently Harris (2014) "A probe has been launched amid allegations that abuse of vulnerable people in Romanian institutions is at ‘crisis levels’." "Mentally ill people are being force fed, deprived of light and subjected to physical and mental violence, according to  a disability charity." The EU commission has allegedly funded the establishments and has commenced an investigation (ibid).See cases described in Russia above.

Seeking updates .

D'Allant (2014) discusses positive initiatives worldwide to care for individuals with mental illness; as she says "it is crucial to do this" to inform others what CAN be done and to generate hope amongst staff, patients, and public. "More than 450 million people suffer from mental disorders, worldwide according to WHO" (ibid)."75% of the mentally ill remain untreated in the Global south". The Mental-HealthCare Bill (2013) India  aims to provide proper  healthcare treatment is provided to people who suffer from mental illness, and seeks to regulate public and private mental health as well as establish  a mental health care system that is integrated in all types of healthcare (ibid).A Therapeutic community approach is described in Bangalore  with half-way homes and long term care for example. Factors that contribute towards mental illness in such countries include poverty, disease, disasters,  and abuse (ibid). A Drug Rehabilitation Centre is described in Cape Town, South Africa. There are issues with mental health stigma (ibid) with some families abandoning the individual. Initiatives are described in Brazil including Pscho-Social Attention Centres (ibid) that offer more human intervention than previous psychiatric hospitals.

Of significance, in UK (RINF 2014) the use of taser stun  guns by police against black Londoners and mentally ill people- has increased. Does this indicate  a total lack of respect and misunderstanding of such people? "Evidence from the London Assembly shows up to 30 percent of people Tasered by the Metropolitan Police are emotionally or mentally distressed. It further shows 50 percent are from black or other minority ethnic backgrounds ". The home secretary has requested an indepth review.

It has been proposed by many that there is "no such thing as mental illness " (see eg Laing); it being considered to be  a reaction to society (Nightingale 2013) rather than simply physiological. A major treatment is medication which may well suit drug industries. In Australia Queensland has the highest use of antipsychotics for children (abc 2014). Interestingly this applies to many children who live with foster familes- could this POSIBLY be linked to Aborigine children who are still removed from their families (Greenleftweekly). " Of particular concern is the use of the medications among children in foster care, where parents are not able to consent to their use" (ibid).  It is noted that the drugs are not prescribed by specialist doctors and there is no specialist assessment, which may be another factors. Drug treatment is all too easy. Once  a person has  a diagnosis of mental illness it remains ."Professor Jureidini said there was no clear evidence anti-psychotics were safe among children, even in the short term" (ibid). ""If you give a so-called anti-psychotic medication to a child with behavioural problems that is a form of chemical restraint" (ibid).

Positive examples hospitals

In the UK 12 NHS trusts have pledged to "raise the profile of patient safety nationally" ( Oxleas NHS Foundation Trust is to lead on this .Continuous learning and improvement is central to the aim , with an open and honest culture (ibid).

Again at Oxleas UK (2014) care on mental health wards was improved based on patient feedback which was gathered by interview , observation, and group discussion. Short films were made based on the interviews and shown to staff and a patients. This approach is to be applauded.


References (2014) Antipsychotic medication Over-Prescribed to Australian Children, Expert Says Australian Hospital Statistics 2012-13,Private Hospitals ack D Scales-wikihospitals

Andersson H (2014) Eighty Mentally iIl Us Prisoners Have Died Since 2003 BBCNews

Andreyev  M (2014) Aged Care is Fatally Flawed abc,net,au 8.9 (ackaussie aged care twitter)

Barrett  J (2014) Problems  in Prison Healthcare Going Undiagnosed,  Watchdog Warns 17.2

BBCnews (2014) Prisoner Suicide Rates Calls For Action On Young Inmates 13.8 Thousands Sexually Abused in Prison, Study Suggests 15.9

BBCnews (2014) Surgeons Told to Publish Mortality Rates or Face Penalties 16.1

Belardi L (2014) In The Place of Their Choice 30.9 (ack Aussie agedcare twitter)

Bird M (2010) Insane Neglect of Romania's Mentally Ill The Diplomat Bucharest April

Booth F (2014) Private Hospitals Should Not Be Singled Out on Patient Safety HSJ 5.9 (acl L Vick twitter for the ref only)

Boyle D (2014) Almost 100 elderly Patients ‘Put To Sleep’ At One Hospital By Doctors Who ‘Almost Certainly’ Shortened Their Lives By Routinely Dosing Them Up With Opiates mailonline  11.7 (ack phso-thefacts twitter)

Champion G (2013) Concerns Raised Over Mental Health Unit Deaths 30.7

Chorley M (2013)  Care Pathway Scrapped After Damning Report Reveals How Relatives Were Shouted At By Nurses  For Giving Loved Ones A Drink mailonline 15.7

D'Allant J (2014) Mentally Ill and Poor :What To Do? 28.4

Donnelly L (2014) Investigation Probes 50 Maternity Deaths The Telegraph 8.12 (ack R Cantwell phso-thefacts)

Doughty S (2014) Don’t Make Our Mistake: AS Assisted Suicide Bill Goes To Lords, Dutch Watchdog Who Once backed Euthanasia Warns UK Of ‘Slippery Slope’ To Mass Deaths mailonline 9.7

Dreaper J (2014) Private Hospitals 'Must Provide More Safety Data' BBCnews 20.8

4bitnews (2014)

Georgatas G (2014) Unpaid Fines Destroy Lives with Jail Time 13.9

Gordon H (2002) Suicide in Secure Psychiatric Facilities (ack Rosemary Cantwell for raising the issue).

Gralton J (2014) Daily Mail Still Goose Stepping Om The Truth About Welsh NHS 23.10

Harris C (2014) Romania:Claims Over Abuse of Mentally Ill People Put's Spotlight On EC's Funding Millions Health Care Industry Today

Hemmelstein DU (2014) A Comparison Of Hospital Administrative Costs In Eight Nations : U.S. Costs Exceed All Others By Far The Commonwealth Fund 8.9 commonwealthfund,org (ackGerry twitter)

Hildebrandt A (2013) Nearly 25% of Canadian Nurses Wouldn't Recommend Their Hospital 4.4

Houle D, Fleece J (2012) Why One-Third Of Hospitals Will Close By 2020  14,3

Hrw.ORG (2014) Russia: Children with Disabilities Face Violence, Neglect 15.9 (ack Roy Lilley twitter)

Hughes S (2014) At The Vaguard of NHS Privatisation 7.11  ack Unisonews twitter

Icke D (2014) (2014) 'Whistleblower brought to Tears' Over Thought of Being Admitted Into Hospital May 13

Kotecha S (2014) To Many Inmates Jailed Needlessly' Says Review Chief 14.11

Lauer C (2013) Chuck Lauer: The Shameful State of Our Hospitals

Leys C. Toft (2014) Patient Safety In private 'Hospitals- The Known and The Unknown Risks CHPI (ack Rosemary Cantwell, phso-thefacts)

Lueng  M (2014) 'Typical' Family Will may More Than $11k For Heathcare in 2014 :Fraser Institute 3.7

Li J, Ran MS, Hao Y,Zhao Z, Guo Y, Su J, Lu H (2008) Inpatient Suicide in a Chinese Psychiatric Hospital August 38 (4)

Lintern S (2014) Revealed The Mental Health Trusts With The Biggest Income Cuts  14.8

MacNicoll A (2014) Problems Accessing Mental Health Units Sees 'Too Many' Mentally Unwell End Up In Police Cells 22.10 ack Gerry twitter 16.10 (2014) (2014) 27.10

Mykyta L (2014) Ludomyr Mykyta: Aged Failings

Marsden S, Davies E,  Bains I  (2014) Labour's NHS Shame Exposed :Mail Investigation Reveals Meltdown in Labour- Run Welsh NHS With Police Probing Allegations of Horrifying Neglect  19.10 (2013) Nearly Half of the Nation's Prisoners are Mentally ill 26.11 (2013) Health Insurers Say Some private Hospitals Offer Costly and Substandard Care 10.3 (ack Delia Scales wikihospitals)

Naish J (2012) It Sounds Like an Upgrade . But Being Sent To a Private Clinic By The NHS Can End in Tears 3.12 (ack Aesthetica twitter)

Nightingale L (2013)

Nightingale L (2014)

Nightingale L (2014)

Novak T (2014) The Crisis in American Mental Health Care RINF

Novak T (2014) Mentally ill in the US: Ten Times more in Prison than in Hospital 18.6

Oregonian (2014) Fed Slams Oregon State Hospital ;Read Report, Previous Stories 20.1

Olsson  P (2013) The Reality of Swedish Neoliberalism 28.5

Oxleas ack R Cantwell

Panorama (2014) Bedlam Behind Bars BBC (7.7)

Patient Exposes the Good and The Bad of Our Hospitals  25.10 (From wikihospitals )

Pragnell (2014) Figures Reveal £5bn spending By Kent and Medway NHS and Social Care Partnership Trust On Private Beds For Mental Health Patients 6,11  ack Gerry twitter

Pollock A (2014) NHS Privatisation Keeps on Failing Patients - Despite a Decade of Warnings 15.8 (ack  twitter)

Prison Reform Trust (2014) Too Little Too Late

RINF (2014) "Death Trap" Prisons ;UK Governement policy 'Responsible' For Soaring Inmate Suicides

RINF (2014) UK  Police Taser Use On Rise Against Mentally Ill, Minorities

The Commonwealth Fund (2014) Mirror, Mirror on the Wall , 2014 Update :How the U.S. Health Care System Compares Internationally 16.6  Ack David Drew twitter

Scales D (2014) Florence Nightingale and Private Hospitals June 19

Serna J (2013) Canada's Universal Healthcare May Not Be So Universal After All 25.2

Sexton M (2014) (ack aussie Aged care twitter)

Smith R (2012) Assaults on NHS Staff Increase to 163 Attacks Per Day 30.11

State of Health (2014) Share Your Bill, Make Healthcare Costs Transparent in California 23.6 (ackJ Pinder facebook)

Sudworth J (2014) China Sees Wave of Violence Against Hospital Staff bbc.CO.UK 28.2

Sully A (2014) Reshuffle Rumours : And The Croc On The Plane  BBcnews 12.7

Syme R (2014) Philip Nitschke Should Not Be The Sole Face Of The Euthanasia Movement 24.7 ack Guardian Australia twitter

Taylor S Dr  (2014) Why Privatisation is Killing the NHS 23.9 Peoples' NHS twitter)

Watt N (2014) Income From Private Patients Soars At NHS Hospital Trusts The Guardian 19.8 (ack Laurence Vick twitter)

wikihospitals (2014) Unaccountable (Ack Delia Scales Australia ) 4.8  Includes Book Martin Makaray (2012) What Hospitals Won't Tell You And How Transparency Can Revolutionise Health Care

wikihospitals (2014) Delia Scale Private Hospitals in Australia- A Radio Interview wikihospitals 9.8

Zheng Y (2014) Former Oregon State Hospital Nurse Sexually Abused a Patient, State investigations Find  20.3



Francis Report (2013)


This report still applies only to NHS hospitals. All NHS hospitals in England are to be Foundation Trusts which are semiprivate and have different regulations and policies (Dimon 2013) .Also NHS hospitals have private beds; more so in FTs. NHS patients are sent to private hospitals. The question is, who is then responsible? The issue of care extends across the board, regardless of who owns the establishment .and similar factors are involved such as attitudes and education .It may be that some recommendations will be applied to the independent sector, including care homes, but not necessarily (Ward nd). Of the 290 recommendations in the report, not all will be acted upon. As the report states, this depends on what recommendations major organisations select.


The Government has failed to act on major findings of this report (Kline 2013), such as staff bullying, some GP practices being forbidden from exercising their duty of candour, and specified minimum staffing levels have again been rejected. Since the Francis report, which many claimed to be a report into an isolated case, more hospitals have been identified with similar problems (Smith 2013)."In 2011 an inquest heard how Hildegard Mikalansky, 67, was admitted to Stoke Mandeville Hospital in Buckinghamshire after a fall and designated as ‘nil by mouth’ by medics due to a risk of chocking. But, it took four days for staff to give her a feeding tube to supply her with much-needed nutrients. By then, the mother of two’s condition had worsened, and she died the following day". A main indicator of problems with patient care are high death rates, but reasons for this must also be considered - such as regional differences.

Yet another horrendous case in the Uk, involving whistleblowing in  a hospital and surgical operations (mailonline 2013). There are as mentioned, cases overseas also. This situation has existed since 1999 as far as is known, and involved at least 50 deaths of patients and threatening of staff including nurses.  Factors relevant, without excusing the situation, include maintaining job and career, fear of repercussions, acceptance of low standards, and  afraid to deviate from the group for example. Unfortunately, there are also fabricated cases as discussed in this book. That is not to say that these are.

Hunt (UK) announced nurse staff levels are to be publicised on hospital wards (Whitnall 2013  ). However, Government still refuse to establish  a minimum staffing level. As discussed in chapter 8 on here, similar dilemmas exist overseas. Eg different needs of different wards. Also as argued within this book. poor care has always happened even with adequate or above, the required staffing level. Andy Burnham    argues problems are more evident now due as indicated by higher  mortality rates, but such rates did not exist many years ago when unavoidable deaths were not investigated (Shojania 2012 ).

BBCnews (2014 )announces "Basic mistakes in hospitals in England cost the NHS up to £2.5bn a year, Health Secretary Jeremy Hunt is to say". The RCN still insist that errors are due to "short staffing" (ibid). As this book discusses, short staffing is not always the case nor always the reason for poor care or errors. One only has to analyse incidents of poor care  along with CQC, NMC, and GMC cases. If this issue is disregarded as it has been for many years, poor care will once again be unspoken of publically if ever mandatory staffing levels are established and met. Most nurses have at some time made an error, however small, and many are able to rectify it at the time.Indeed a record of "near misses" would be useful. As stated in this book with the support of references, errors continue to occur on intensive care units with  a one nurse to one patient ratio. Such errors may include communication, the wrong patient being approached, or drug errors however small.

The pilot study for potential student nurses to work on hospital wards for one year in England, has commenced (HEE). This involves 200 staff in 6 districts. Whilst doubts remain about this, it may well serve to ensure that more appropriate individuals enter nursing , and that they are al able to provide fundamental care. As this book discusses, nurse education is inadequate at present. This project is being overseen by the RCN, NMC and CQC. The RCN have particularly opposed the project as discussed within this book. Again- the private sector and care homes, are ignored.

A review of the Francis report after  1 year,  undertaken by people affiliated to the NHS (Nuffield Trust 2014). Still the emphasis is upon the NHS, with the ignorance of underlying themes that promote poor care .in any establishment, in any country, by any person. The report is based on  a small sample of 48 NHS people including directors, governors and staff from 5 trusts . There are many other sources of information- ordinary voices, that remain ignored. However, it is indicated that the Francis reports has had  a positive affect by for example, encouraging staff to question practice more.

Duty of Candour for the NHS and FTs  introduced October 1st (2014), to apply  to other sectors owned by different bodies later. "The Duty of Candour places a new requirement on providers of health and adult social care to be open with patients, and to apologise, when things go wrong" (IBMS 2014). This law requires NHS or FT hospitals in England  to tell the  truth to patients and relatives if there is significant harm to the patient. No such rule previously existed, as  highlighted by the case of Robbie Powell, leaving relatives and others in torment. This duty of candour is also known as Robbie’s law following years of campaigning by Will Powell and his family, who lost his son due to medical neglect.

Debates will  remain concerning what is significant harm-  is this physical or psychological? . Near Misses" do not have to be reported. Also nursing care or care by healthcare assistants, may cause harm in some cases. It is however  a move in the right direction.

 Pomphrey (2014) does debate whether or not this will assist litigation claims . Many people however, just seek the truth.

As discussed in this book, in the USA nurses or Doctors may be sent to prison or heavily fined for such as falsification of records. Govt guidelines do identify maximum penalties for certain offences in England eg failure to protect service user  from abuse £50,000.However, these guidelines only apply to providers registered with the CQC - not all staff as in the USA ( ).


In Australia there is to be a  state-wide closure of public aged care beds in Victoria  (Australian Nursing and Midwifery Federation 2014). The Australian Government had previously denied these reports. As in the UK and USA , there are concerns that standards of care in the private sector will be lower than in the public sector with lower staff levels for example. "Private nursing home staffing is usually made up predominantly of personal care workers who are unregulated" (ANMF).


References: (2014) Statewide Closures of Public Aged Care Beds Imminent (March 7)

BBCnews (2014) NHS Errors Costing Billions A Year- Jeremy Hunt 16.10

IBMS (2014) Statutory Duty of Candour Comes into Force 1.10,753

Kline R (2013) Never Again? Jeremy Hunt's Response to the Francis Report is Inadequate: (17.4.).

Mailonline (2013) 10.11 Damning Dossier of Chaos in Surgery That shames the NHS (ack Cure the NHS for reference )

Nuffield Trust (2014) The Francis Report: One Year On

Pomphrey G (2014) 3.11

Shojania KG (2012) Deaths Due to medical error: Jumbo Jets or just small Propeller Planes? BMJ Quality and Safety qualitysafety.bmj

Ward N What Effect will The Francis Report Have on Independent Healthcare Providers? (nd)

Whitnall A (2013) Patient safety Crisis The Independent 19.11

Foundation Trusts:

There are additional services that may be reduced in order to cut costs within FTs. There are reports that hospital chaplains may no longer be used (Vine 26.6 2013), as they are not considered to be an essential need. Who will spiritually comfort the distressed , dying patient, or relatives? Chaplains have already been reduced in NHS hospitals (Strangeways - Booth 2013). Even patients of differing faiths may wish to talk to a chaplain.

There are to be no FTs in Northern Ireland .

See the equivalent health agencies in NI below.

England - CQC.

Northern Ireland - The Regulation and Quality Improvement Authority (RQIA -


England- Healthwatch/Monitor

Northern Ireland - The Patient and Client Council (PCC -

England - NHS England.

Northern Ireland - Health and Social Care (HSC).

The integrated health and social care system in Northern Ireland is unique and is officially called ‘Health and Social Care’ or ‘HSC’, rather than the NHS.

England - Health Ombudsman/Local Government Ombudsman.

Northern Ireland Ombudsman. The Northern Ireland Ombudsman can deal with complaints about: a government department or agency, local councils, health services, education services (

England - GP Consortia.

No equivalent in NI.

(Dept of Health, Social Services and Public Safety NI 2013 by email)


All regulated establishments in NI  must have  a complaints procedure which meets relevant minimum standards. Patients or relatives  can raise complaint with HSC trust if the patient is placed by them. Otherwise  they refer  to  the ombudsman. RQIA does not investigate individual complaints, similar here to CQC - keep records and refer. RQIA will review matter if there is a breach of regulations (RQIA email 10.2013).

In Scotland, care homes are regulated by the Care Inspectorate, which is an independent body. Scotland has their own national care standards to use when regulating and inspecting care services. These standards also apply to independent hospitals and other sectors of care. The Care Inspectorate will investigate complaints from individuals- public or staff members and has  a clear complaints procedure. Complaints can be accepted by letter, phone or email for example.They will encourage use of the establishment's complaints procedure first, and will refer to other agencies such as the police, if necessary.

Complaints may finally be raised with the Scottish Public health Service Ombudsman regarding NHS and Councils, for example but not private care services.

NHS hospitals are inspected by Healthcare Improvement Scotland.


All healthcare in Wales; private or NHS, is inspected by the Healthcare Inspectorate Wales. There are 7 local health boards who plan and deliver services . Community Health Councils still exist in Wales.CHCs aim to improve and monitor quality in NHS services. They are described as being independent- some are council members or known to the council (

Similar to CQC England, HI Wales, do not investigate individual complaints but do wish to be informed of them. The Care and Social Services Inspectorate Wales, inspects care homes according to the Welsh standards,  but again do not investigate individual complaints.

Relatives of residents in council owned care homes in wales, have been banned from visiting if they complain, or the home has threatened to move the resident to another home (Hughes 2012). People who complain very much fear repercussions on the resident. Despite complaining to the council, little has been done. Freshties a voluntary group in Cardiff, is campaigning for voluntary visitors to visit residents in carer homes; which this book also recommends.

The Public Services Ombudsman in wales,  will investigate some complaints regarding NHS patients  in  hospitals or NHS funded patients in private hospitals  and nursing homes. but similar to England, there are  criteria to meet. Private paying patients in hospital or care home, are expected to seek the advice of solicitors which may be expensive and stressful for many.

There are also voluntary bodies such as Age UK, who will advise.

In all 4 regions of the UK, as in other countries, it appears that complaining especially about the private sector, is  a difficult process. One issue may be that there is no alternative for care provision. Yet complaints can be dealt with and could be used by the establishment as  a positive indicator if well resolved .

There is a list of 18 FTs who failed to meet regulations in England, according to Monitor, between 2009-2013, such as failure to meet targets or financial problems ( Since then, over half of all FTs have failed to meet A and E targets (4.6 MONITOR). Reasons for this have to be considered, such as difficulty accessing community services and type of patient problem. Does the failure of FTs speed up the Government's aim to privatise? (Dimon 2013). Yet there are differences between the private and voluntary sector, such as means of complaining (Dimon 2013).

It is important, as this book states, to note also the many examples of good care within all fields, regardless of who owns it. For example biguptheNHS ( and care homes such as Myhomelife. However again, poor care must not be ignored and staff or others, need not be afraid of raising issues.

By April 2014, there are still 40% of NHS trusts that are not FTs (Kings Fund 2014).39% of FTs were reported to be in deficit December 2013. What of quality of care?  Recall FTs have no Government involvement.

As this book foresaw, hospitals now have many fast food establishments within their establishment (Donnelly 2014). Of course FTs are semi-private and aim to make  a profit with no government involvement. People fail to recognise the difference as long as their care remains free. Costa Coffee and Greg's bakery are amongst the companies.


References: 11.121.13) (ack Care Inspectorate)

Dimon C (2013) Understanding Privatisation of The NHS Through Foundation Trusts (wideshut 6.8).

Dimon C (2013) Private Healthcare Versus Statutory

Donelly H (2014) NHS Hospital Cafes 'are Helping to Fuel The Obesity Crisis' 2.8 (ack H Donnelly NHS complaints facebook)

Hughes B (2012) campaigning visitors threatened with care home visiting bans walesonline 22.7

Kings Fund (2014) (ack Chris Ham twitter)

Smith R (2013) Mid-Staffs : 14 Hospitals Under Investigation The Telegraph (4.9). (accessed 11.11.13)

Strangeways- Booth A (2013) Chaplaincy Services Cut in 40% of English NHS Hospital Trusts ( 26.6).


Chapter 5 Attitudes

As in this book (Berry 2012) comments that care reflects the values of society. One conclusion of this work was that problems in care extend way beyond the patients bedside. Comparisons have been made to problems of whistleblowing in care to secrecy within other incidents such as Saville in the UK (David Drew twitter and others ). This may seem extreme and upsetting to many but other situations are similar such as the Hillsborough disaster when causes were covered up for multiple reasons such as self protection, fear or personal gain. A driving force is politics. This underlying issue needs further exploration.

Attitudes  are generated by neoliberalistic aims of politicians thus  "American cities are blocking individuals and ministries from feeding homeless people in parks and public squares, and several Americans have been ticketed for offering such charity, according to a forthcoming report by the National Coalition for the Homeless To date, 33 cities have adopted or are considering such food–sharing restrictions, according to the coalition, which shared with NBC News a draft of its soon-to-be published study".  (Briggs 2014).People are encouraged to blame the poor for their own position. As this book states (Lutherian work ethic) "you must work harder".  The fact that jobs are scare and many jobs are zero hours- is not considered to be  factor.People are commodities and are owned by corporations who strive towards  profits. This attitude festers throughout society.


Debates continue about one cause of dehumanisation of patients being stress or burnout of staff in an Italian survey  of 108 nurses (Triffiletti et al 2014). As supported by Goffman (1961), Norton  et al (1975),Smith (1992), amongst others.

It may well be that excess routine provision of care is used as  a barrier, to prevent closeness of staff to patients in addition to saving time; it may be that staff shout or display negative attitudes due to stress. It may be that there are even cases resulting in physical abuse of patients, or even staff by other staff members. However, stress cannot be viewed in a vaccuum. Other factors include support of staff, resources, and staff levels for example. Nor should stress be used as an excuse .for the delivery of poor care. Recall evidence of cultural and political influences upon attitudes  .and behaviour as discussed

Something positive from Amsterdam  (Brimelow 2013). District nurses in a non-profit making company spend more time with patients, and also provide care such as "clearing up the kitchen", "So the costs per hour may be higher, but patients need thirty-to-forty per cent fewer hours of care". Factors may include the absence of managers, community support, and socio-political system .


See Sweden above- Lex Sarah law

Australia (Webb 2013) are discussing whether ro not to criminalise mistreatment. This is a matter of debate in all countries. The question is linked to what is regarded as mistreatment for example, the refusal of  a drink, errors, or more severe, intentional abuse? The management of  abuse in Australia, as in USA, differs from state to state. Mandatory reporting is required within the USA of cases of abuse.

Nightingale (2014) analyses the use of cameras in care homes, questioning what "lies beneath the tip of the iceberg?" He states, The continuous reporting of abuse in American care facilities led to the passing of the Elder Justice Act (EJA) in 2010, which established  mandatory reporting requirements for those suspecting abuse in long-term care facilities (EJA, Funding for training and certification, 42 USC, sec. 1397, 2010). All employees are required to report  reasonable suspicion of abuse to the Secretary of Health and Human Services and law enforcement agencies  Failure to report can result in harsh financial penalties of up to $300,000." In Canada (Leung 2013) highlighted the case of  a hidden camera in a Toronto nursing facility recording  an elderly resident being roughly manhandled as her incontinence pad was changed, having a soiled wipe shoved into her face; an employee wiping his nose on her bed sheets; employees having sex in her room as she lay in bed. Four employees were sacked, but did not face any legal charge."

Whilst cameras are used in England on paediatric wards to identify abuse by parents, their use in other areas such as care homes is still under debate. Issues of consent have been addressed in USA.It was found that nursing home businesses opposed the ruling to use cameras, and  within some states, residents who use cameras, may be asked to leave by the home owner.

Cameras are discussed further below


China introduced a law (2012) legally requiring children to visit their elderly parents, and employers to give them time off work to do so (nydailynews 2013) "China is projected to have 636 million people over age 50 - nearly 49 percent of the population - by 2050, up from 25 percent of the population in 2010, according to the U.S. Census Bureau. So who will care for them? " (ibid) . There are very few nursing homes in China and they are very expensive (ibid).Other countries such as India require children to financially support their parents. There are parents in China who sue their children for not caring for them. However, as this article indicates, caring for relatives is not easy- financially, physically, or psychologically. Many countries are facing this problem including the UK, which links to the issue above of sending old people abroad.Whilst there have been research studies regarding  the difference between cultures and attitudes towards old people, is the underlying link attitudes which drives the need for people to work to survive? That is one proposal of this analysis.

Work ethic

The influence of the work ethic on attitudes of people needs more exploration (Weber/Luther). It is possible that the work ethic- aiming for prestige and work, promotes such attitudes as prejudice against the poor or minority groups (Hutson 2012);so called non-contributors.Thus promoting selfishness and reluctance of some  to help others.However, the work ethic may no longer be connected to religion as it once was.



Berry Rev JC (2012) Care of the Vulnerable Elderly : The Crisis in Modern Medicine Catholic Medicine Quarterly v62n1

Brimelow A (2013) Dutch District Nurses Rediscover 'Complete Care' Role 13.5 BBCnews  (ack Ros Tyalor twitter)

Goffman E (1961) Asylums Penguin

Hutson M (2012) Still Puritan After all These Years 3.8

Nightingale L (2014) Hidden Cameras in Nursing Facilities 11.7

Norton D, Maclaren R, Exton-Smith AN (1975) An Investigation of Geriatric Nursing Problems in Hospital Churchill Livingstone

nydailynews (2013) Elderly Chinese Woman, 94, Sues Her Daughter For Care As Aging Population Presents New Problems For Governments 12.10

Smith P (1992) The Emotional Labour of Nursing

Trifiletti, E., Di Bernardo, G., Falvo, R., & Capozza, D. (2014). Patients are not fully human: a nurse's coping response to stress Journal of Applied Social Psychology DOI  in ack twitter HSJ 2014

Triggle N (2014) Hospital Failure Regime Extended to Care Homes BBCnews 16.7

Webb E (2013) The Mistreatment of Older People 6.6 (ack  the conversation, twitter)




Chapter 7 CQC.


There are many reports of the failure of the CQC, such as their failure to deal with complaints concerning Winterbourne View care home for individuals with learning difficulties (Calkin 10.12). Since then , there have been other reports of poor care. At a hospital in Cumbria, 16 babies and 2 mothers died (2011-2012), and 9 infants were brain damaged as a consequence of poor care (bbc 2012). Yet, evidence was deleted from reports by members of the CQC, about which the government vows to take action (Harding et al 2013). The question remains, who encourages such secrecy ? This is a major issue arising from this book. A veil of secrecy exists concerning many issues that effect the lives of people, with people denying such issues exist and refusing to discuss them.


The CQC, in response to criticism, has restructured its board and inspection team (Vinegar 2013). The question is how are they selected? The CQC is described as being an "independent" body. Complaints about the CQC may be made to the CQC National Contact Centre, or can be made directly to the Chairman/Chief Executive/Commissioners under the Corporate Complaints Policy and Procedure. Finally, a complaint can be taken to the PHSO ( How easy is this process? The PSA regulates the CQC, and concerns can be raised with them. According to Swinford (2013), inspectors with no clinical experience, such as firemen, were used as inspectors of hospitals and care homes. The CQC has now expanded it's use of inspectors to include more clinical professionals and lay members.

CQC now reports incidents to the police (bbcnews 2013). How far can this go/ technically, any issue that opposes patient rights may be reported to the police by any staff member, relative or resident. Such issues include- not being given a drink, enforced out or bed,  in addition to clinical issues.

Several whistleblowers have been recruited by the CQC, noticeably most from the NHS. The CQC does indicate they are prepared to listen with encouragement to individuals to comment on services via their web site

134 inspectors have been recruited to the CQC in 2012 after failing competency tests (Donnelly 2012); records of reasons for their recruitment have been "destroyed". "It is claimed they cannot be got rid of for fear of being sued" (ibid), "1in 10 inspectors-- should never have been given the job". Training is also said to have been inadequate. This supports claims of  a former CQC inspector as discussed in this book. Have some people lost their reason d'etre ?

Latest proposal concerning care Homes (England) is to apply special measure rules as in NHS hospitals (Triggle 2014). Such practice already exists as LA may withdraw LA funded residents from care homes that are of  a low standard compared to those required by the LA and orders may be given by the CQC. If residents are withdrawn from the home, there is  a risk the home may subsequently close plus it will have implications for the meeting of the safeguards. There is evidence however, that this process may not have been applied as often as it ought to have been. This 'new approach', may reinforce such action. Updates wanted from other countries.

Donnelly (2014) reports that CQC did not close unsafe homes when it was legally challenged. Some inspectors were overruled by senior inspectors, as discussed in this book. The problem may go way beyond this politically- consider politicians with interest in  private companies for example .(Nightingale 2014). 'It was not until under cover footage was revealed concerning abuse, that action was taken'; does this not support the use of cameras?  There are many whistleblowers who raised issues despite threats of being sued or what may happen to them. One's conscience is  a huge factor. One aim of this book was to explore this.Lilley (2014) offers additional reasons for the CQC failing to close care homes such as there is nowhere else to put the residents "Insiders at the CQC confided; they couldn't do that because if they closed the home there was no spare capacity in the system and nowhere to decant-yer-granny. Added to which they didn't have an 'A-Team' of super managers poised to parachute-in and run the place properly." "It has since emerged, in total, more than 750 care homes have been found to be failing on one or subsequent measures for at least 12 months" (ibid). As Lilley says, the "mum" test proposed by the CQC (would I want my mum to be here?) may not stand up in court.

Despite these failings it is reported that the CQC will no longer undertake annual inspections for adult services that have been deemed by the CQC to be outstanding or good (Carter 2014)."But whereas annual inspections were introduced two years ago to address concerns that the previous risk-based approach was leading to poor care being missed, CQC chief inspector of adult social care Andrea Sutcliffe makes “no apologies” for reintroducing this approach" (ibid). The evidence is however, that situations have not improved within care homes. Is this simply  a cost cutting exercise?

Meanwhile Sutcliffe of CQC (2014) reports that "too many care homes are truly awful". Where is the sense in stopping inspections? She describes abuse, neglect, or loss of dignity.


USA. Ornstein, Groeger (2014) outline sanctions given to nursing homes , state by state. Nursing homes are fined if they do not meet the standards- which do differ per state. However, there are also national standards set by CMS (Camerow 2014). Ornstein, Groeger (2012) discuss 2 cases in 2 different states that were dealt with very differently;  "Federal fines vary widely by state. Homes in some states pay a steep price for misconduct while those in neighboring states don’t." "“The enforcement system is broken,” said Charlene Harrington," (ibid).

Northern Ireland.

RQIA is equivalent of CQC in NI. Regulation and Quality Improvement Authority

Regulation of nursing and  homes is to be reviewed in Northern Ireland following reports of poor care in care homes highlighted by the BBC (Connolly 2014) . The review also includes domiciliary care. Clearly the current system does not adequately protect those who rely on it for their care." (Claire Keating in Connolly 2014)."The report also highlighted that complaints and concerns raised by staff, relatives and residents were not properly dealt with by the health regulators, the RQIA" (ibid). Speaking of Cherry Tree House nursing and residential home Keating said "  "The fact that this home continued to operate for years, in spite of persistently failing to meet the necessary standards, is shocking " (ibid). The investigation by the BBC into this home was based on reports made by a whistleblower.


References: (2013) 'CQC Can't Hide Behind Data Protection' (20.6) (2013) Colchester general Hospital: Police Probe cancer treatment 5.11

Briggs B (2014) Food Feud: More Cities Block Meal Sharing For Homeless ack Are We All Asleep?twitter

Calkin S. (2012) 'CQC Inspector Disciplined Over Winterbourne Whistleblower Failure (Health Service Journal 8.8)

Camerow A (2014) U.S. News' Best Nursing Homes- 2014

Carter R (2014) CQC Chief Unapologetic Over Dropping Annual Inspections To Focus On Poorest Providers 23.9

Connolly M-L (2014) NI Care Homes : Commissioner Begins Review into Regulation 13.8

Donnelly  L  (2014) One in Ten NHS Watchdog Staff Should Not Have Got The Jobs 10.7 (ack Gerry - Twitter)

Donnelly L (2014) We Failed Elderly Because We Were Too Scared Care Homes Owners Would Sue Us , Watchdog Admits (ack L Donnelly twitter and several others since)

Harding E, Borland S, Cohen T, Chorley M (2013). 'Hospital Cover-Up Culprits Will Be Named: Government Vows to End Secrecy Over Who deleted Evidence About Unit Where 16 Babies Died' (mailonline 19.6)

Lilley R (2014) No One Answers 12.8

Ornstein C, Groeger L (2012) Two Deaths :Widely Different Penalties: The Big Disparities in Nursing Home Oversight 17.12

Ornstein C, Groeger L (2014) Nursing Home Inspect 14 June

Sutcliffe A (2014) Too Many Care Homes Are 'Truly Awful', Watchdog Chief Warns  (ack Ann Ditch twitter)

Swinford S. (2013) NHS Watchdog 'Sending Firemen and Dentists' to Inspect hospitals' (The Telegraph 26.6)

Vinegar D. (2013) 'Will The CQC Survive It's Latest Crisis'? (The 21.6)


Chapter 7 CQC (10.10.13)


CQC to be independent  of the government (informationdaily 2013). This depends what "independent " means. Many bodies are described as being independent, yet they are linked via government funding or members of high profile committees or jobs. If the CQC is to be privatised, questions arise concerning its regulation as the government is then not responsible for it. 

The introduction of 6Cs by the DH  is a response to Francis report and applies to the  NHS only. There are ambassador nurses who promote the 6C's ;  care, compassion, competence, communication, courage and commitment (nhs.england 2013) . 

These ambassadors are often students. There is  a danger such people may be specifically selected and nominated by individuals who views they represent. There is also  a danger that they may become ostracised as may anybody who dares to challenge practice. Yet hopefully, it may generate compassion and motivation  as evident on such channels as twitter. It may also be  a means of blame again being shifted to certain individuals, away from other factors as discussed in this book.

Star Ratings

Meanwhile, evidence of poor care continues in all sectors and countries. As described in the book, several inspection bodies exist in USA depending how care is funded for that patient. In 2013, the CMS (Centres for Medicare and Medicaid Services), rated all nursing homes according to 5 stars. the stars referred to quality, state inspection results and staffing. Out of 16000 nursing home, only 3036 gained  a 5 star grade (Camerow 2013).One wonders what will happen to the other homes? Thomas (2014) discusses the limits of star ratings by Medicare   in the USA  "top-ranked nursing homes have been given a seal of approval that is based on incomplete information and that can seriously mislead consumers, investors and others about conditions at the homes" (New York Times ibid).Much self-reported data from the nursing home by  is used for the rating. Negative information such as fines,  is ignored by the rating  (ibid). In Rosewood nursing home with  a top rating, "Many residents live three to a room, and there is often a scarcity of basic supplies like washcloths, as well as a shortage of quality staff, according to interviews with current and former patients, their families and statements from former employees" (ibid). Medicare plans to use similar ratings for hospitals. Some comment that ratings give the public "a  false sense of security " (ibid).

The CQC (England) is reconsidered star ratings for care homes and hospitals but they too may be misleading. Indeed, they were ceased 10 years ago when found to be ineffective (Calkin 2013). It depends who is assessing the home and on what basis.  


Poor nursing care still exists in the Uk across the country ( 2013). "Anne's husband John was hospitalised following a stroke". the nurse explained  we just tick the sheet to indicate patients have had  a shower when they have not. After waiting nearly one hour to be assisted to the toilet, John tried to take himself and subsequently fell, following which he was scalded by  a nurse.


In Australia,"Staff say they often do not get time to properly feed, hydrate or toilet residents" within nuring homes. There is no mandatory minimum staffing level. Pads are restricted in some cases, to 3  a day per resident. Anecdotal evidence informs us, this occurs in the UK also. There is  call in Australia for "transparency" as in the UK. Staff are forbidden to document certain things. (O'Neill 2013).

Since most cases involve vulnerable older people, and those in nursing homes, it may well further indicate the low regard that others have for such" non-contributors".

This is further fuelled by the business aim of such organisations as nursing homes, as O'Neill indicates. 

It is encouraging that the information for the abc report, came from staff who contacted them. This is the transparency that is needed .but it is needed also, within the establishment itself.





A care home in England which was closed in 2011 and owned by  a large company Southern Cross healthcare, was found to harbour terrible examples of care with huge cover-ups by all staff until the administrator informed the police. Such care resulted in several deaths of residents, drug errors and severe neglect with evidence of low staffing ( There is  a need for cameras within all areas of care home and hospitals with patient and relative consent. The CQC is debating this. In USA the voluntary care home group Nursing Monitors, exists to combat abuse in nursing homes and was established by relatives of residents   in 1995 ( One thing this group does support, is the use of monitors, controlled by family members,  in residents' bedrooms. There is also a  demand from campaigners, for cameras in residents bedrooms in nursing homes in Australia

Some hospitals in USA do have cameras (Makary 2012) and this author gives an honest account of near-misses that do occur but can be avoided.5 states in USA are now required to have cameras in nursing homes (Hoffman 2013) following reports of poor care. The sites include New Mexico, Oklahoma, Texas.Without cameras some poor care such as latex gloves being stuffed in  a person's mouth, would never be known about. Cameras have also been found to identify cases of falsified records where it can be proved that care was not given at the set time. There have also been more cases in the UK (bbcnews 2014).

Caya (2014) cameras also highlighted falsification of records and failure to give pain medication ;" eight nurses and nine nursing assistants, were fired following a state investigation" of  a care home in Michigan, USA "; the nurses and certified nurse’s aides claimed to have filled out medication and care administration forms, while video surveillance shows the contrary."

Additional points to consider are offered by Nightingale (2014) based on international analysis, "

If it was deemed that hidden cameras had a role in protecting a child from an abusive parent under the Children Act of 1989, then why do they not have a similar role today in protecting such as the elderly from an abusive or neglectful nurse or nursing assistant?

Recall also that cameras are used within prisons certainly within the UK.

The whole issue is a contentious one. Who would review camera and audio footage? What  guidelines would be issued that defined abusive or neglectful care? What rights would there be to appeal?"

Following a further exposure by TV Panorama 30.4.14 in UK, one care home company (HC-0ne ) is to commence using cameras in residents' bedrooms. This may also be a good marketing tool and residents and relatives would be asked if they wish to agree (Brindle 2014).

UK problems

There are many reports of poor care within private care homes in England that are hidden from public view . For example, 7 homes in Cumberland  were closed by the council due to poor care such as lack of food; not by the CQC. They were able to close the homes because the care homes accommodated mainly council funded residents (Parsons 2013). Further, 3500 care homes in England have been illegally run without  a registered manager for several years, of which CQC were aware ( Brindle2013). The CQC now promise to act upon this. Problems of this are further discussed on Ross (2014) says there are now more than  2000 care homes in England without  a registered manager. A registered manager is ultimately responsible for everything within the care home, whilst acknowledging that their actions may at times be restricted by higher managers or owners. Meanwhile, why are these homes allowed by the CQC to continue to operate?

 Devon privately owned care home for people with learning disabilities, had  a dungeon to lock  residents in (Gregory 2013). Found after CQC were finally informed. Yet the DH insist the private and charity sectors , are not the responsibility of the government. Such care is not due to low staffing, unless the excuse is unable to cope with a restless resident. Reasons or contributory factors, may include cultural attitudes, societal attitudes eg work ethic and shear abuse.

More reports of poor care in Australian residential homes including restraint and over sedation . A new Quality Australian Aged Care Agency is to commence 2014 with quality indicators. See comment below;

"During my complaints process, my father and I have been continuously subjected to lies and unprofessional behaviours by the aged-care facility including verbal excuses for their behaviour that contradict the documented evidence (including emails) supplied to the Complaints Scheme. Within about one month of lodging each of my complaints with the Aged Care Complaints Scheme my father has been forced to lie in his own faeces: three complaints and three times this has occurred." ( 12.11.13)

O'Neill (2013)

Reports of poor care in Welsh NHS hospitals (Johnston 2014), with neglect of  a patient- not all will be due to short staffing. The issue is care and no place is immune to poor care.

Mental Capacity

 A UK study has been undertaken in response to cases of patients being detained within care homes especially, or their rights being opposed according to the inappropriate use of the Mental Capacity Act (2005)( Morrison 2014). Some cases published within the newspapers  eg Sergeant 2013, indicate this may be done to prevent relatives from being involved within the care of residents if they are considered to be interfering for example, or to maintain control of the resident, or to keep the bed full. As this book discusses, within all 3 countries, there are cases of relatives being banned from the establishment in response to complaining, or the patient being asked to leave.Similar cases  occur within mental health facilities in particular, and within the USA and Australia. In Australia, this particularly applies to the detention of Aborigines (Georgatas 2013). One may compare this to some cases within prisons.

One factor is, the difficulty of defining mental capacity. Even without the Act , this has been used as a reason for opposing  a patient's decision (Dimon 2006) in some cases; "the professional knows best." Again, there is  a need for an independent advocate for patients within hospitals, care homes or any healthcare establishment including prisons. This especially applies to the most vulnerable patients such as the mentally ill or individuals with learning difficulties.

Brown (2014) explains clearly the problems with Mental Capacity and Deprivation of Liberty Safeguards . Whilst his work refers to the police, it is of immense relevance to care. Brown gives an example of the decisions involved with these regulations "Earlier this year, the Supreme Court had to reach a verdict in the case of Cheshire West – this case concerned a group of young people from both Cheshire and Sussex who were living in supervised accommodation because of their learning disabilities and were not at complete liberty to exercise autonomy.  They were not permitted, for example, to go to the shop as they pleased or to visit who they wanted without consent and supervision of staff.  The various hearings in lower courts led to much debate about what a ‘deprivation of liberty’ actually was and the Supreme Court had to determine this." Brown asks "So do you have a ‘power’ to convey or return a DoLS patient to a care home for example, if they refuse to return from visiting a relative they had permission to see or if you find them after they were missing?" Staff in care homes especially, may face such dilemmas on a daily basis.

In the UK, the NMC has stopped a nurse manager from working for a year   after she banned a relative from visiting a resident  who was passing away (Nottingham Post 2014). Is this sanction enough? What could such relatives do in residential homes where staff are not generally nurses and not registered?  One wonders if regional managers were aware.This could well be  a police matter according to human rights.

Secretary of State for Health  Report published June 2014 regarding the Mental Capacity Act 2014 ; " Too many people who may lack capacity may be missing out on the legal rights that the MCA gives them " (p3).This report followed  a 10 month investigation by the House of Lords Select Committee.The conclusion is the Act has  " suffered from a lack of awareness and a lack of understanding". 39 recommendations have been made such as "overall responsibility for the mental Capacity Act-- should be given to a single independent body". Again the question is- what is independent? Whilst "100s of  mental capacity advocates" have been appointed, it is essential to remember care homes which do differ. Indeed, there are not necessarily any nurses working in residential homes. Deprivation of liberty Safeguards also apply and the process of application of this does differ in care homes as discussed. Again, nursing students are not prepared for working in care homes or the private sector . Overseas staff should also have a standardised course on entry to the UK which involves such regulations and their application. p29 does highlight 'a lack of awareness and understanding of the regulations by staff'. Again the nursing degree course needs to be standardised to a higher degree.

This book recommends that all residents within care homes should be offered an independent advocate.

IN USA mental capacity may not apply with this example, but it is  a similar issue , Wells (2014) describes a case in Texas “Social workers” are detaining Charlie against his will, placing him in a psychiatric ward and ultimately a nursing home for being crazy enough to not want to be a government prisoner during the little time he has left on this Earth." A hearing was done without the patient. In Texas it seems they have "protected care";

  • That a person is likely to cause serious harm to himself,
  • Likely to cause serious harm to another, or they must also show
  • That a person will substantially deteriorate without state intervention   useful resources Deprivation of Liberty



BBCnews (2014) North West Somerset Care Home Staff Sentenced for Ill-Treating Resident

Brindle D (2013) Orchid View Inquest: Care Home Regulation Has  along way to go The Guardian 22.10

Brindle D (2014) Care Homes Chain to Use CCTV in Resident's Rooms to Help Stop Abuse The Guardian 28.4

Brown M (2014) Deprivation of Liberty Safeguards 12.9

Caya C (2014) Hidden Cameras Used To Catch Alleged Nursing Home Neglect 25.4 In Lenin Nightingale to be published

 Clakin S (2013) 'Star Rating' Style System Back on the Agenda for the NHs. Health Services Journal.

 Cameron A (2013) US News Best Nursing Home 2013 healthyliving.msn nhs.england (2013)

Dimon C (2006) Decisions and Dilemmas in Care Homes Fivepin. This book now needs updating, but does give examples of such dilemmas in practice.

Georgatas G (2013) Australia's Aboriginal Children Detained At The World's Highest Rates 2.5 

Hoffman J (2013) Watchful Eye in Nursing Homes

Gregory A (2013) 7 workers 'arrested' after dungeon found in care home. 23.10 (2013) (1.10)  NHS Watchdog to become independent

Johnston L (2014) Scandal Rocks NHS Again as Nurses held in hospital death probe 16,1 (ack phso the facts)

Makary M (2012) ‎ How to stop hospitals from killing us . The wall street journal 21.9 Residential Aged Care Report Says People are being Shackled, Assaulted, and Turned into Zombies (12.11)

Morrison S (2014) The Great mental Health Betrayal :Inquiry Slams Appalling Unlawful Detention of Tens of Thousand Vulnerable People The Independent 13.3

Nightingale L (2014 ) Hidden Cameras In Nursing Facilities

Nottingham Post (2014) Care Home Boss is banned Over Appalling Behaviour 28.3 (Ack

 O'Neill M (2013) Aged Care Workers Cite Abuse and Neglect of Nursing Home patients (14.8)

Parsons (2013) Cumbria care homes forced to closed after damning reports Cumberland News 17.9

Ross T (2014) More Than 2000 Care Homes Have No Manager 5.10 (ack Yourcarehome twitter)

Secretary of State for Health (June 2014) Valuing Every Voice, respecting Every Right: making The Case For The Mental Capacity Act ack phso-thefacts Rosemary Cantwell.

Sergeant H (2013) I had to Rescue my Mum From a Private Hospital as The Nurses There Were so Callous Daily Mail December 2013 p44-45

Thomas K (2014) Medicare Star Ratings Allow Nursing Homes To Game The System 24.8 (ack L Sparrow twitter)

Wells R (2014) (Watch) State Elder Abuse, Man Incarcerated For Crime of Being Old 2.3 ack trouble  - shooter twitter


Chapter 6 Intellectualisation of care


Debates continue in UK regarding training and registration of care assistants. In USA, some states have mandatory, college provided training for nursing home assistants and homecare assistants. Such courses are  a minimum duration with specified content and result in registration of that individual to work in that state only ( In all countries, there is  a reduction in the number of nurses being used. Whilst this is so, carer assistants need improved training.

Questions remain about the adequacy of nurse training. As this book discusses, they are inadequately prepared for work in care homes or the private sector for example.  Would it be  more appropriate  to consider a 6 month specialist course in the UK? Considering blogs, many student nurses consider that nurse education is inadequate. Many students leave training due to the pressure of assignments for example, as discussed. Has nursing become lost in the aim to become  a profession and whose need does this serve?

Findings in this book, concerning the variability of nurse education in the UK and inadequate preparation of nurses, support findings of the NHS Future Forum in 2012.

"A Swedish study has shown that many nurses in training feel unprepared and anxious when faced with the prospect of meeting patients during end of life care" (ehospice 2014). This was based on the interview of 222 nursing students. Of course training will differ to within the UK but there is some evidence that this may also be the cases here .All people have different attitudes towards death. Much  has been  written about the subject historically (eg Marcus Aurelius). It is these underlying attitudes, beliefs, and experiences which will affect how one deals with it  and to some extent, their philosophy of life. This is more than  simply  a matter of training. As the author comments "Nurse education can play a more active role here by discovering at an early stage which students experience strong anxiety about meeting and caring for dying patients, and offering these students guidance, training and support" (ibid).

Aiken et al (2014) appear to support the fact that more standardisation is required concerning nurse education- and across Europe "Hospital mortality varies substantially within European countries. Our paper provides scientific evidence that failure to standardise nursing education at the bachelor's level puts patients at higher risk of dying after common surgeries". The difficulty is, policies, standards due to culture and research, and resources in each country in addition to knowledge and experience of lecturers.


In N Ireland the prceptorship support and education of newly qualified nurses, is said to be manadatory in all arae4s whther private owned or NHS ( is not to replace induction (ibid).

Fake certificates remain (Nightingale 2013) as discussed in this book. The UK is to accept many people from Bulgaria and Romania, which is supported by some major nursing bodies . Yet there is evidence of  vast number of fake certificates within all fields in these countries

 ( 2012). Again, unfair on people who do have genuine certificates apart from patient care in the UK. meanwhile, the NMC still has given no evidence of whether or not they check the validity of certificates against a list of approved universities.

The number of overseas nurses working in UK has increased (Macrae 2013 ). The NMC are not allowed by EU, to check the language of nurses from within the EU, nor the equivalence of their course to that in the UK. Labour ask why the number of student nurses has been reduced. Meanwhile, there is still no official figure for the number of newly qualified nurses in the UK, who do not obtain jobs as nurses.

More evidence of fake certificates; UK seems to be the only country which fails to act (Nightingale 2013). "Half of all higher education certificates are false", including PHD (Bear, Ezell 2012). Even then, individuals are able to pay for dissertations to be written. All types of fake documents are readily available by internet on several sites.  In California, 5 nurses were arrested with fake certificates from the Philippines (Board of Registered Nurses California 2013). It is frightening that nurses or doctors may well be working without any form of training- let alone other professions.

More reports of fake certificates- mafia gang arrested in Bulgaria (2013, 1000 plus fake nurses in Arabia ( 2013), China. All countries acting, but not the UK it seems. Actual case of inadequately trained midwife in UK from Bulgaria ( 2013). Attitudes also differ between cultures. Again, unfair to put overseas nurses in such positions- not to mention patient care at risk.

Supporting these cultural findings Express and Star (2013) announce that 2 nurses involved in a situation within a hospital at Mid Staffs, have been allowed by the NMC to remain on the register- with a caution and retraining, They failed to attempt to resuscitate an 81 year old lady during the night and recorded that she was sleeping when she had died. Both nurses worked on the night shift and claimed it was due to short staffing. Reading the NMC record of the hearing, explains several other factors included failure to record observations.  A relevant factor would be to consider where both nurses were trained in general nursing.

In Australia (ANMF) a report recommends replacing nurses with nursing assistants. Meanwhile still many newly qualified nurses in Australia as in the UK and USA, cannot get jobs (ANMF). Standardised training is recommended and  a limit on the scope of practice of  assistants.

A study in New Zealand indicates that many newly qualified nurses leave due to pressures such as shift work and stress. Few expected nursing to be  along term career. This has important implications for the education of nursing and their support. New staff tended to be treated unfairly "Some "old-school" wards still operated with a fierce hierarchy, where new staff were treated more like cleaners and worked the shifts no-one else wanted including public holidays"  (Turner 2013).

UK government now proposes to introduce national training care assistants in care homes within 12 weeks of commencing work. As discussed, this was  a previous requirement of inspection standards which was ceased as few homes were able to adhere to it. Arising issues include difficulties if home is to deliver and assess the training such as how staff will attend or managers have time and they will teach their methods. An alternative is to consider programmes such as the  6 month pre- training course in Florida as discussed, and  a nationally devised content of sessions which adheres to national procedures. However , whatever the training, other factors may still oppose this in practice including resources and dominant staff. National training also to be introduced within the NHS which has different issues.

Need for  a nurse at all  in nursing homes is officially being discussed in Australia (nurse uncut 2014). Depends on definition of "a nurse". Is the question duration of training? Recall the 6 months programme in Florida as discussed.

Update fake certificates (Nightingale 2014) - are fake certificates or qualifications, becoming the norm in some cultures? Is the issue overruled by business objectives of some universities who encourage greater intake of foreign students offering more fee? Lenin distinguishes between "counterefeit" and "genuine fake". Counterfeit is copied professionally, from the original type. Genuine is obtained from accepted universities by individuals who work there,

" Yes, there are companies that will perform checks on documents supplied by foreign students, these services are not cheap, can not guarantee to eradicate all cases of cheating, and are not used by most UK universities, who often use a ‘does-it-look-genuine’ approach.* Cynics will not be surprised by this. Whilst debt-ridden UK degree students typically pay £9,000 per year for their education (among the highest rates in the world), overseas ‘cash cows’  are ‘milked’ of upwards of £35,000 per year for the same degree. In 2013, the House of Commons Education and Skills Committee accused universities of being “driven by short-term gains in fee income”.(Nightingale2014).

Gregory (2014) announces NMC  will no longer require  overseas  nurses to do adaptation programmes but instead will do online multiple choice tests and an exam . Very concerning regarding the risk of falsification. Previously paediatric nurses from within EU undertook a test- as NMC stated, nurses had  a choice of doing the test or an adaptaion programme which could be any duration up to 3 months.To update- NMC.

An actual case nursing UK- published with  a  Zimbabwe newspaper - not UK news (Agencies 2014). A nurse completed the qualification but had fake prior certificates. Coventry University became aware ONLY after  a tip-off.This does not mean that Coventry University deos not check certificates as Lenin Nightingale's article (2014) clearly illustrates. "But last November the university later stripped her of the nursing certificate after an anonymous tip-off she got on the course by deception" (ibid).

 The NMC declared (McFarlane 2013) "they have no idea how many nurses work with fake certificates"- this remains true. Establishments and individuals, will gain more respect if they accept issues are occurring and take action- as many issues with this book illustrate. See cover-ups below.



Agencies (2014) Nurse Banned in UK Over Fake Zim O Levels

Aiken LH, Sloane DM, Bruyneel L,Grifiths P, Sermeus W (2014) Staffing and Education of Nurses And Hospital Mortality the lancet

v384 issue 9946 p251-252

ANMF (2014) - Skills and Jobs but What About Care? 14.4

Bear J, Ezell A (2012) Does your Doctor have  a fake Degree?  (13.6.12) (2014) Student Nurses Feel Unprepared When Faced With Patients At The End of life 4.9 (acknursingsuni twitter)

Expressandstar (2013)

Gregory A (2014) Thousands of EU Nurses Will no Longer Require UK Work Experience to Treat Patients In Britain 26.8 (ack A Ditch twitter) Also

Macrae F (2013) mailonline Foreign Nurses Still Propping Up The NHS 25 November

McFarlane J  (2013)

Nightingale L (2013) ‎(2012) 27.2 Re: Medical degrees from former Soviet countries are under question

Nightingale L (2014) Fake Degrees and Commercialisation of Universities

Nurse Uncut (2014) Every Nursing Home as  RN- but For How Much Longer ? (28.5) ack HSG LGBT staff forum twitter

Turner A (2013) Young Nurses Find Work Tensions Cruel 5.8


Chapter 8 care in the balance :Staffing levels 

This chapter outlines  a UNISON report regarding staffing levels. there are of course, additional studies such as that by the RCN. Whilst evidence of low staffing cannot be denied, nor can the effect upon care, poor care may exist when staffing levels are higher. This is evidenced within this book. The question remains, is the issue- not enough staff, or is it not enough qualified nurses? Also required levels may well vary between specialities; intensive care or long term care of older people for example. Care as discussed within this book, varies between specialities such as coronary care or a long term care .Is it more the vulnerable areas of care which suffer?

In USA, California is the only state that has  a minimum staffing level in  acute  hospitals (Schultz 2013)  ,debates and evaluation continue. Having  a minimum staff ration in California, which varies per speciality, was found to  "increase staffing levels and create more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios. Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios" (AHRQ 2014). This article also indicates how such changes may be implemented  Staff levels need to apply to all sectors in UK including NHS, charity and private, whether care home or hospital. USA has researched the effect of  a minimum staff level in nursing homes (Park. Steams 2009) . Conclusions include conflict with profit motive, less use of restraint and there are additional factors besides staffing. There are many other studies such as Hyer et al (2007) regarding nursing homes in Florida. This involved Medicaid subsidising the nursing homes in order to increase staffing levels.

Finney-UC Davis (2014) asks should mandatory staffing levels be applied to all USA states? She provides some evidence of the benefit of set staffing levels in California - the only state with mandated minimum nurse- patient ratio since 2004. The study was lead by Paul Leigh and concludes that there was a large reduction in the number of injuries including needle-stick incidents causing injuries to nurses, and less moving and handling injuries of nurses. Some hospitals argue against having a mandatory nurse level because of increased financial costs (ibid).

"In South Australia there is no legislation regarding staffing levels, however, the award or Enterprise Bargaining Agreement in the public sector for nurses have determined minimal staffing levels (staff to patient ratios) – this does not affect residential aged care. There are no such agreements or regulations in the private sector or the private hospitals and anecdotally they do not have enough staff.

In residential aged care - a registered nurse has to be available for careworkers to contact, and staffing must be seen to be adequate in meeting the standards set by the federal government. " (Anita De Bellis, Australia by email 25.10.13)

"In Queensland, there are staffing levels set under the ‘business planning framework’. This is only in the public sector. This framework incorporates how many staff per patient, skill mix, and the degree of nursing care required.(eg palliative care)The private and aged care sectors do not have a patient to staff ratio, and QNU encourage  staff to put in workload forms that protect their practice and encourage the placement of extra staff." (email from Queensland nurses' union 25.10.13). The campaign for mandatory staffing levels in Australia continues ( 2014)." “It’s time the state government got its priorities right. Spending $872 million dollars of taxpayers’ money over six years on industry assistance to the minerals and fossil fuel industry has not improved care available for our ageing population or put patient safety first in our public hospitals.” (NSWNMA in 2014).

A mandatory nurse level is to be set for public owned nursing establishments in Australia (ANMF/nurse uncut 2014). Whilst this is  a start, it is needed aslo for the private sector as this book indicates.

Thousands of newly qualified nurses are still unable to find jobs in Australia (ABC news 2014) and as within the UK, nurses from overseas are being employed instead." "It can't be a coincidence that at the same time as thousands of new nurse graduates across the country are unable to get jobs, the same amount of people are getting jobs, coming in as temporary skilled migrants on 457 visas," Annie Butler, acting federal secretary of the Australian Nursing and Midwifery Federation, said" (ibid).Hospital managers argue this is due to the need for greater skills and experience.Brett Home (NSW Nurses and midwives Assoctaion ) commented " "Is it just that they are seeking experienced nurses, or are they seeking nurses who will form a more compliant workforce, totally dependent on their employer for their ability to stay in Australia?" which supports discussions within this book. (2014) "The Federal Government has appointed an expert panel to review the current regulations on employers accessing skilled labour offshore, including nurses and midwives. The ANMF has made a submission focusing, in particular, on the high numbers of new nursing and midwifery graduates who have been finding it difficult to get work and we want to hear from recent graduates about their experiences". According to ANMF "graduate nurses and midwives are being ignored"  by some employers.

 In china there are public and privately owned care homes and hospitals. There is  a great shortage of nurses. Recruitment of staff is very difficult. In one nursing home, staff ratio was found to be 1 to 7 patients (Jaili 2012), Nursing homes in China have been rare in the past ( Orenstein 2011 ); increase due in part to restrictions on one child per family. There may further be differences in staffing levels between specialities as Baeyens 2010) indicates when considering staffing levels of old people in wards between several countries.


In Japan there is  a shortage of nurses due partly to severe testing of nurses ( and robot nurses are being developed (, One wonders how flexible they will be with individual patients?

As discussed, Japan has  a "very stringent test" for overseas nurses (Del Callar 2014). This test is to be relaxed (ibid) in order to attract more Filipino nurses and caregivers. 6 months of pre- paid language training is required plus nurses and caregivers have to work in Japanese caregiving facilities for " 3 and 4 years respectively" (ibid). During that time they are trained and paid accordingly. Unlike other countries. Training of staff seems to depend on supply and demand rather than quality in many countries .

No shortage of nurses in the Philippines- hundreds cannot get jobs (McGeown 2012). The issue seems to be, do we need qualified nurses to provide care? The RCN argue we do, and they all need a degree. Yet other countries seem to be considering alternatives such as Florida.

Robots everywhere now it seems (Gibson 2014) ; retirement homes in New Zealand "Armies of robots escorting retirement village residents, reminding them to take medication, monitoring blood pressure and behaving like electronic friends - their role in caring for New Zealand's elderly arose at this week's Retirement Villages Association annual conference." An additional use of comfort has been discovered (ibid).Whilst many care staff and nurses remain without jobs,  Is the aim to find cheaper services- or are they more efficient? ‎


A study in USA has made the first link between ownership of care homes by private equity trusts, and lower staffing (Fernandez 2011).

"From 2003 to 2008, these chains had fewer nurse “staffing hours” than non-profit and government nursing homes when controlling for other factors. Together, these companies had the sickest residents, but their total nursing hours were 30 percent lower than non-profit and government nursing homes.

The 10 largest for-profit chains were cited for 36 percent more deficiencies and 41  percent more serious deficiencies than the best facilities. Deficiencies include failure to prevent pressure sores, resident weight loss, falls, infections, resident mistreatment, poor sanitary conditions, and other problems that could seriously harm residents." The top 10 chains, operate 13% of USA nursing home beds .(Fernandez 2011). Findings indicate, the most serious problems occur in the largest for profit chains (Harrington in Fernandez 2011).

In the UK, 13 out of 40 care home employers, were found to fail to meet National Minimum Wage- further investigation is being done (hmrc 2013). Reasons for this include deductions removed from wages and failure to pay travel time. and. Increasing levels of non-compliance  with NMW were identified, over the last  2 years  based on survey of 200 people. Penalties- fines- can be given for non-compliane with NMW. This study will have huge implications for staff from overseas, many of whom may be unaware of the regulations or are prepared to work for less pay.

There are additional conflicts between profit -making and care. In USA, some privately owned hospitals provide unnecessary tests such as scans and blood tests- in order to make profit or reduce litigation claims.  Eisler and Hansen (2013) discuss unnecessary operations in USA.. Patients are not allowed to refuse. According to private sector complaints procedures, which also applies to the UK, patients could be asked to use the service of alternative providers. Such unnecessary testing of patients also applies to other countries such as India (Nandan 2012). Also in Uk (Pallat 2012), along with hiding data such as infection rates. This is another issue that extends far wider than hospital wards. Dentists also found to provide unnecessary treatment (Naish 2011) for example.

More evidence of hyped charges  in USA (Devon 2014) "The American medical industry has become a con, an economic hoax, bloating prices to unthinkable levels for simple medical services". Nightingale (2014) discusses also, coporative  money-makng aims of blood plasma doning.

In Australia babies born in private hospitals may suffer more problems not helped by unnecessary use of some procedures  (Safi 2014).

The article by Lenin Nightingale "Who Owns care homes", extends far wider than care homes. Indeed some NHS hospitals are owned by Virgin Care but keep the NHS logo on display (Wynne -Jones 2013). The question - is this a private equity trust? Who is responsible for the care- not the government it seems, if it is run by a private company. Also they do not have to adhere to NHS requirements eg staffing levels (not that there are any at present) as discussed in this book. All patients should have  a choice and be fully informed of who owns that service. Regarding private equity trusts however, it is hard to say since the shareholders own the company.


There are suggestions that claims of  a shortage of nurses, are fabricated (Williams 2013  ).This is possible when many newly qualified nurses in USA, Australia (nurseuncut.com2013)  and UK are unable to obtain jobs. In the UK there is no official figure but it would be easy to obtain. Nightingale (in Dimon 2014) suggests the number of UK nursing students, which the government pays for, who cannot get jobs as nurses in the UK, is  2 thirds, based on blog analysis and analysis of job adverts. Most adverts require nurses with 6 months experience. 

It is recommended that UK nursing students be guaranteed a job at the end of it, as once was the situation in the UK. Several webs, and articles, discuss overseas agencies who offer staff to hospitals and care homes .eg Howle 2011.

More evidence newly qualified nurses in USA cannot get jobs with adverts specifically stating "no newly qualified nurses" as in the UK (Bello 2014).

As discussed within this book, there has been a reduction in the employment of nurses  in general (due to frozen vacancies) , and an increase in the employment of overseas nurses within the UK.

In the UK, newly qualified nurses are said to "lack basic care skills necessary " (RCN 2011). NHS would not employ some newly qualified nurses due to poor numeracy skills regarding drug calculations (Lintern 2014). Whilst the evidence is described as anecdotal, similar evidence exists regarding other issues and reluctance to employ newly qualified nurses. The number of blogs and evidence from nurses,  is rather more than anecdotal. Hence the problem of relying on research which is restricted due to available funding and topic (Dimon 2014).

In Victoria, Australia, nurses have been campaigning against similar situations to the UK including split shifts ,low staff rations,  "sweat shop conditions" and  replacement by lower grade staff (Morrow 2011). Between 5000 and 1000 nurses marched through Melbourne. In response, the Health Services argued that they are concerned about quality of care and it is not only about money (Cook 2012 et al).

In Vancouver (Sun 2013) nurses in hospital,  are campaigning against their replacement with care assistants who have been  trained for 4 months.

Since similar issues arise in many countries- could not unions unite?? Also needs addressing by researchers, but we know there are political/funding issues.

Whilst there is a figure for newly qualified UK midwives who cannot get posts in the UK, one still does not exist for qualified nurses- apart from Nightingale's at 2 thirds. Figure for midwives is said to be around 35 % (RCM 2013 in; in 2011 it was 50% (Smith) . Of course the validity of this figure has to be considered. It may be obtained by contacting  each University , but are the posts full time and permanent? In some cases of nursing, they are part-time/temporary /bank and zero hours. There is also the private sector to consider. Meanwhile, many places continue to use overseas staff- who may in some cases, have fake certificates which cannot be detected, apart from different  training .and attitudes.

Another perspective from the USA "nearly 1 in 5 new nurses leave their first nursing job within  1year" (Boltz 2014), "hospitals have lower turnover for this group than other settings". "The data comes from surveys of three cohorts of newly licensed RNs conducted since 2006. (ibid).Reasons for turnover need considering and may have been done in the main study such as inadequate preparation of nurses for their role. TTP (Transition To Practice) indicates that this may well be  a factor ( "Over the years, NCSBN and boards of nursing (BONs) have looked at the issue of training and retention of new graduate nurses. They have found that the inability of new nurses to properly transition into new practice can have grave consequences". There are indications of this possibility also with the UK as this book discusses and it is one reason why employers are reluctant to employ newly qualified nurses. TTP reports of stress and a high number of medication errors in particular.When health institutions use transition programmes, improvements do result (ibid). The report also recommends more standardisation in nurse training.


An international study, concludes that less degree nurses on acute surgical wards, increases death rates (nursingtimes 2014). Many questions remain including the number of care assistants and content of the degree undertaken by the nurses, or where it was undertaken. Indeed reasons for individual deaths  also need to be considered.

Nurse vacancies remain in UK (Triggle 2014) as trusts seek more experienced staff especially for certain areas such as accident and emergency; Triggle and the RCN argue more pay should be offered, "these posts are not being offered with high salaries." As this book discusses, cheaper alternatives to qualified nurses are being sought.Overseas nurses do often work for less pay. Pay levels are also usually less within the private sector.


There is to be  a staffing guidline of 1 to 8 nurses on hospital wards in England (Triggle 2014). It has to be clarified whether or not this applies to Foundation Trust hospitals (in which the government has no involvement), the private sector or care homes. Also will nurses replace health care assistants?  Events such as delayed pain control are to be monitored, which will act as triggers to the need for more nurses or staff. Will they be given or available?  Since this staff level applies only to acute areas, will nurses be removed from "continuing care areas" such as old people, mentally ill, or people with learning disabilities in order to increase levels on acute areas? As discussed in this book, the role of HCA is very different from that of  a qualified nurse. The perceived role also differs between nurses. Will the use of more "nurses" generate further, government consideration of the length of the nurse education course?

"The guidance also applies to Wales, although it will now be up to ministers there whether it will be applied.

 In Scotland, hospitals are already routinely monitoring and publishing staffing levels - although there are no recommended minimums." (ibid)

A USA report (ABC news 2014) finds low staffing in nursing homes "endangers patients". Of course it does and there are also other factors . as the report suggests ."After eight years of research, health officials concluded that understaffing has contributed to increased incidences of severe bedsores, malnutrition, and abnormal weight loss among nursing home patients. " 54% of nursing homes in USA are said to be below the proposed minimum standard of 2 hours care  a day per resident from nursing aides (ibid). 12 minutes a day of care per resident are proposed and 31% of nursing homes in USA fail to meet this.

There  are more indications that nurse or staff shortages may be regional.

Another aspect that may concern short staffing- attacks on staff. Williams (2014) discusses the case involving  a carer working alone at night in  a care home, who broker her spine after jumping out of  a window to escape a schizophrenic resident who was about to attack her. This residential home is  run by Potensial LTD. She was alone with 6 mentally ill residents.A minimum staffing level may have avoided the situation but not necessarily if the other staff member was somewhere else at the time.Of course he or she could have raised the alarm. Other factors include risk assessments and treatment of the patient.


This issue is further heightened when considering the involvement of some politicians with private companies, which may conflict with their role  (Nightingale 2014), "nearly 40% of the most powerful individuals with healthcare are from companies with links to Lords and MPs." Nightingale lists donations from companies that have been made to several MPs of all parties. This may well apply to other countries and needs further research where possible.

Yet more evidence of the link of politicians to healthcare; social investigations (2014) identified 76 MPs who have, or have had, financial links to private health care companies or individuals, "The Members financial interests represent every stage of the healthcare value chain from advisors to private equity firms funding the private healthcare companies, to having shares in those same companies." This may well bias their support of privatisation and it's regulation or handling. Further, the BBC chief was also financially linked to Care UK, a private equity trust which owns several care homes ,"Lord Patten, the current head of the BBC has direct links to a company heavily involved in private healthcare" (socialinvestigations2012). It appears he has recently retired due to ill-health.

 It is essential when researching issues in one country, that studies within other countries are considered. Whilst political backgrounds may differ to some extent, similar issues do arise regarding care.

In (2013) Corporate Watch announced that some private companies who own health services in the UK are not paying tax enabled by a legal-loophole."The care companies known to benefit from the loophole are: Partnerships In Care (several of whose mental health facilities have recently failed inspections), Independent Clinical Services, Priory Group, Acorn Care, Tunstall, Lifeways, Healthcare At Home, Spire Healthcare and Care UK" (Corporate Watch 2013). Could this be linked to the many MPs who invest in some of these companies?

Seeking recent updates.


In the UK, more concerns regarding privatisation and monopoly control by big companies (Morris 2014) with again  a "veil of secrecy" described referring to hidden contracts and scandal cover-ups.


ABC news (2014) in Australia Nurses and Midwifery Federation Thousands of Nursing Graduates Unable to Find Work in Australian Hospitals 26.5

ABC news (2014) Report: Understaffed Nursing Homes Endanger Patients 23.7

AHRQ (2014) State Mandated Staffing Levels Alleviate Workloads Leading To Lower Patient Mortality, and Higher Nurse Satisfaction (2014) Renewed Calls for State Government to Prioritise Public Health and Patient Safety 

 Baeyens MP, Closens MC (2010) Differences in nurse (aid) staffing in acute geriatric department in general hospitals in Europe European Geriatric Medicine v1 n 5 p320-322 October

Bello R (2014) The Nursing Shortage Paradox

Botlz K (2014) Nearly 1 in 5 New Nurses Leave Their First Nursing Job Within  One Year 2.10 (ack Nurse Science Watch twitter)

Care Watch (2013) Firms Running NHS Care Services Avoiding Millions in Tax 28.10 (ack Rochelle Monte twitter)

Cook K,Daveneson S,Lily A, Murphy B, Park S, Way A (2012) Staff fears over patient ratios and split shifts are misplaced The Sidney Morning Herald 6.3

Del Callar M (2013) Japan Eyes More Filipino Nurses, Caregivers GMA News 10.1

Devon L (2014) Hospital charges

Dimon C (2014) Staff shortages: Who is kidding who? Nursesfyi January

Dimon C (2014) What is Research?

Eisler P , Hansen  B (2013) USA Today Doctors perform thousands of unnecessary surgeries June

Fernandez E (2011) Low staffing and poor Quality of Care at Nations For Profit Nursing Homes  UCSF Nov 29

Finney-UC Davis K (2014) Should States Mandate Nurse- Patient Ratios? 24.11 Science Watch t

Gibson A (2014) Robots on The March Into Retirement Homes New Zealnd Herald 28.6

HMRC (2013) National Minimum Wage Compliance in The Social Care Sector (ack Deb Claridge Twitter

Howle M (2011) Spanish and Portuguese Nurses Fill the Gaps in The NHS The Guardian 20.12

Hyer K, temple a, Johnson CE (2007) Florida's efforts to improve quality of nursing home care through nurse staffing standards, regulation and Medicaid reimbursement Journal of Ageing and Social Policy v21n1 p318-337

Jaili G (2012) Nursing Staff quality falls short  30.3

Lintern S (2014) Exclusive: Concerns Emerge Over Nurse Numeracy HSJ May14

McGeown K (2012) Nursing Dreams Turn sour in the Philippines  5.7

Morris N (2014) Government Accused of Deliberate Attempt To Cover-Up Fraudulent ,Incompetent, And Embarrassing Outsourcing Contracts The Independent 13.3

Morrow W (2011) Australian Nurses Rally in Defence of Wages and Conditions World Socialist Website 25.11

Naish J (2011) Are you seeing the dentist too often? mailnline Pointless X-rays and needless check ups could be adding  up  to a rip-off 22.4

Nandan D (2012) Private Hospitals will have to display treatment costs

Nightingale N (2014 )How Many Politicians Have Their Fingers in The NHS Pie? (2014)Politicians Have their Fingers in the NHS Pie? (2013)' I am a nurse who is not a nurse'

 Orenstein D (2011) Nursing Home Boon in China Has Little Government Involvement 15.3

Pallat J (2012) Hospital patients ' Overtreated and overcharged  The telegraph 23.10'
 Park  J . Steams SC  (2009) Effect of state minimum staffing standards on nursing home staffing and quality of care. HSR Feb 44.1 p56-78

Safi M (2014) Babies Born in Private Hospitals 'More Likely' to Have Health Problems The Guardian 21 May ack twitter

Scultz D (2013) Nurses fighting state by state for minimum staffing Kaiser Health News 24.4

Smith R (2011) the Telegraph Student midwives 'struggling to get jobs despite shortage ' 15.11

socialinvestigations (2014) Over 70 MPs Connected to Companies Involved in Private Health Care  17.7

socialinvestigations (2012) BBC Chief Lord Patten of Barnes,Bridgepoint, and The Conflicts of Interest socialinvestigations.BlogSpot 22.3

Sun C  (2013) Nurses Campaign against Island's Health Changes to Hospital Patient Care Victoria News 29.11

Triggle N (2014) Nursing: Are we Facing A Trade -Off? BBCbews 17.6

Triggle N (2014) Hospitals Get Guidelines on Safe Nurse Numbers 15.7

Williams D (2013) The nursing shortage myth. The healthcareblog

Williams A (2014) Terrified Care Home Worker Broke her Spine Jumping From a Window To Escape Sex Attack By Schizophrenic Who Hacked His Way Through a Wall To Get To Her 17.9 mailonline (ack R Cantwell - no relation to person in article)

Wynne- Jones R (2013) How private firms already run NHS hospitals by stealth Daily Mirror 29.5


Truth about Welfare Spending Chapter 10

In the UK, Government announce cap of £72000 to be put  on residents'  fees for care  homes. This does not include usual living costs; hotel and accommodation. (Dominiczak 2013), so it could be £150,000 in reality . Of course care home fees are more expensive in some areas eg London. Return to the details within the book of Germany sending old people to cheap care homes abroad. Is this to happen in the UK? Or are we all to care for our family and friends? To the affluent, this figure will mean nothing.

One relative received a breakdown of his aunt's care in a Barchester owne care home after he requested it several times ( Dyson 2014). His aunt's fees had almost doubles from 2001 to 2013. The list given does not seem to include the set amount of money that is given to investors in private equity trusts   before the profit and loss is made or costs come out (Nightingale 2014). Private paying residents do pay more than LA funded residents. Hence alternative means of caring for old people are sought such as within China (as discussed) or sending people abroad.

In the UK, if people are eligible, the Local Authority pays an amount for care home care. If this does not meet the charge by the care home, relatives or the resident, are expected to pay  a top-up ie an additional fee. This may well be an illegal expectation, with some districts requiring ALL care home fees to be topped up. It also may lead to Local Authorities offering even less payment per resident ( Morrison 2013 ).Individuals seeking care homes, may well be in a position to negotiate payments but being under pressure at the time, may be unable to seek advice .In USA/Australia (as in this book) we have care to some extend funded by insurance companies but similar situations arise.

More reports (Lacey, Foulkes 2014) of people  being sent abroad to care homes. This concern is discussed within this book. It could well occur here in the UK. People really ARE a commodity.


Professor Sir Mike Richards Chief Inspector of hospitals (Wright 2014) declares the NHS is not perfect and their is  "a blindness amonst NHS supporters to this." People have been in denial about poor care for many years as this book discusses. However, the benefits of the NHS are free care to all apart from some extras in some cases such as adequate hearing aids,  different complaints procedure to the private sector, and national policies .

The number of old people is increasing in all countries, with huge dilemmas of how to pay for their care when in some cases families are unable to care for them (as further discussed in this book). In Japan an insurance system has been devised to respond to this.

Noticeably, abuse still existed when families cared for the individual as within other countries.(Holder 2014). Again is abuse and poor care, reflective of attitudes and expecatations? In addition to such factors as stress.

Despite GPS being NHS funded in the UK, they are paid bonuses for certain treatments for example McCartney (2014) states "The determination of Hunt to ‘improve’ diagnosis rates of dementia has meant that commissioning groups are offering a ‘bonus payment’ of £200 to ‘any practice that increases the diagnosis rate by 5 per cent’. The average practice taking this work on can expect to receive 37p per patient for doing so. Yes, it feels grubby to me too."So the incentive is once again profit meaning profit for drug companies and businesses.As this book reports, there have been cases of misdiagnosis of dementia, and there is no absolute test. Screening (ibid) "would also pick up 23 people as having dementia when in reality they did not. " "We have to wake up to the fact that screening turns well people unnecessarily into patients" (ibid), as the author states- far worse in the private sector.Is the aim to make profit, avoid looking at simple causes of memory loss, or to label people as lacking "mental capacity"? Not suggesting this should be the case in general with people who suffer from dementia--.



Waldman (2011) explains that in USA " hospice care has evolved from its charitable roots into a $14 billion business run mostly for profit,". Patients are said to have "given up their rights" for curative treatment. Christine Krebbs (ibid ) executive director of  a hospice stated "“A vulnerable and voiceless population is preyed upon for money.” There have been several lawsuits in the USA regarding neglect of patients in hospices (ibid)."More than 4 in 10 Americans " die in  a hospice (ibid).Death appears to be big business. "The government is investigating whether Vitas “engaged in an extensive scheme” to “defraud the Medicare and Medicaid programs of potentially hundreds of millions of dollars” by falsifying records and hospice certifications, and billing for services it didn’t deliver" (ibid). This echoes SERCO in the UK (prisons) . "A whistleblower lawsuit brought by a former social worker for hospices run by Atlanta-based Gentiva Health Services Inc. (GTIV) said her job was to talk people who weren’t dying into believing that they were" (ibid). Is this an aim to keep the hospice beds full? There were indications patients were kept in the hospices far longer than usual.  "Vitas expects to boost profitability without affecting “the care we provide at the bedside” he said (Keith J Mcnamara in Span 2014).There were also claims that Vitas refused to pay staff overtime. announced "The reality is that hundreds of articles promote a "Mary Poppins" view of hospice so that the public has no idea of the problems that can arise in hospice, until it is too late". This statement may well be applied to many countries regarding all fields of care .Various factors are identified within USA hospices including the lack of specialist care at weekends so patients may remain in pain, Cases of fraud have been identified with false claims being made to Medicare, the public image of "compassion" overrides and thoughts of poor care possibly occurring- " one well known large hospice had over 200 pages of violations written up in the State inspector's report yet the public were unaware of this" .Choice of hospice is the responsibility of the person needing it or the relatives, yet glossy adverts may persuade them.Each hospice aims for the "biggest market share" (ibid).

It is possible hospices may be taken over by private companies within the UK. Recall- the government then abdicates responsibility. Politically, is this failure to care influenced by profit making priorities? Hospices in USA are rarely closed down and inspections are infrequent (ibid)."Hospice industry representatives are very concerned that they might lose donations to the local hospices if people knew the truth about abuses by hospices"(ibid). Exclusive referral arrangements are made between some hospitals and nursing homes (ibid). This may be  connected to the links that directors or investors may have between the two-. has has been the case with some care homes in the UK. Hospice staff who have complained about standards of care have been intimidated (ibid). Whilst this is an early article (2001) some of it appears to still apply today.There is of course, excellent care as the authors point out.

Key factors include- reports of poor care are withheld from the public in order to maintain profit making. The compassionate perception of the service- similar to the rest of care- is difficult to challenge or question . People do not seem to believe or want to know about poor care. Maybe this is because they have little option of using the services?

In The UK cancer  and end - of  life services are beginning to be privatised (Peedell 2014) "the NHS has announced it is tendering a huge £700 million contract for providing NHS cancer care in Staffordshire and Stoke-on-Trent, along with another £500million for end of life care in the region"

"It is remarkable that the cancer charity MacMillan has got involved in this process to help guide the commissioning process" (ibid). Consider the issues with charities being government linked,  as discussed in this book. Of course this issue does not necessarily refer to hospices or solely to them.

As this book discusses there is evidence in UK of some charities being politically gagged,Cook (2013 ) writes "behave like big businesses, although they don't have shareholders and pay dividends". "News of the latest pay rise for the chief executive of St Andrew's Healthcare, a charity, brings an extra dimension to the controversy about senior pay in the sector. His 18 per cent increase of £101,000 brought his salary to £653,000 - still considerably less than the more than £840,000 paid to the chief executive of another charity, Nuffield Health.". Why set up as charities and not businesses? There is clearly a need for them. Does it enable the Government to maintain control- without responsibility?


Cook S (2013) Editorial :The Charity Health Sector Has The Real Mega Salaries (ack Shibley twitter)

Dominczak P (2013) Pensioners Face Care Bill of £150,000 plus (15.12)

Dyson R (2014) 'Nursing Home Billed Me £600,000 - For What?' telegraph 18.1  (ack yourcarehome twitter)

Holder H (2014) Japan's solution to providing care for an ageing population? The Guardian 27.3 (2001)Why Hospice Organisations- Don't Want You To Know The Truth

Lacey A, Foulkes I (2014) Exporting Grandma to Care Homes abroad  5.1

McCartney M Dr (2014) Turning Well People into Patients  27.9  (ack Gerry twitter)

Morrison J (2013) Malpractice over care home top-up fees needs to end The Guardian 22.7

Peedell C (2014) Outsourcing Cancer Care- The Biggest and Most Reckless NHS Privatisation Yet? 14.3 (ack DEmindblower twitter)

Waldman P (2011)  Preparing Patients For Death Lets Hospices Neglect End of Life  22.7

Wright I (2014) Chief Inspector of Hospitals: 'People Might Believe In The NHS . But It Doesn't Mean It's Perfect'. The Independent 17.8 (ack Patients First twitter)


Chapter 11 Regulation of Health Care Assistants

Whilst debates continue in England, Scotland is requiring  support workers  in care homes  to be registered by 30 September 2015 (Jackson-Brown 2014). Hopefully problems of registration for any professional will be amended . Registration does involve  a yearly fee, to an overseeing body. Registration in Scotland will be with the SSSC (Scottish Social Services Council) who hopefully do not have the same issues as the NMC regarding who appoints the main committee, and restraint of the code of conduct. Yes there are benefits to registration as Jackson-Brown discusses  such as accountability - or is this merely shifting responsibility or blame?




Joseph-Brown K (2014)  Will Compulsory Registration Of Support Workers Improve The Quality of Care in Care Homes? 25.7  ack @UKQCS twitter


Chapter 12 Whistleblowing

Of course, in addition to the RCN, there are other unions in the UK such as UNISON and UNITE. there is also a voluntary run organisation ACAS which offers advice and mediation for people in all fields, who are not union members. The RCN continues to be the main union for nurses, and also has students and care assistants as members. However, their total figure of members does not specify the number per role. Hence it appears that they actually represent approx. just under half of UK Nurses. Does this support their claim as being the main voice of nursing? Indeed the RCN has so many national and international links to bodies and Associations (Nightingale 2013) it may well be controlling certain aspects of nursing to a large degree. Despite the fact that as Nightingale suggests, some of the associations seem to be in conflict with RCN aims regarding members. As Nightingale comments , would the RCN publish or support, alternative views to their  own?

The main Union in Australia for nurses and midwives, is the Australian Nurses Federation. This is the only union specifically for nurses and midwives, unlike other general workers union. This union has  a branch in  every state eg Queensland. Interestingly campaigns on Queensland website, reflect those within the UK such as staffing and stress of nurses. There is also a campaign to dissuade the government from selling the public sector hospitals, to become all private. A report commissioned by them in 2001 and again in 2004, concluded the following

 (Hegney, Plank, Buikstra, Eley 2005  on

  • "Nursing is emotionally challenging and physically demanding;
  • Workload is heavy;
  • Skills and experience as a professional nurse are poorly rewarded (remunerated or recognised);
  • Work stress is high and morale is perceived to be poor and deteriorating, similar to 2001;
  • There are insufficient staff and the skill mix is inadequate; and
  • Most nurses cannot complete their work to their level of professional satisfaction in the time available"

 Interestingly, the ANF display on their website, an outline regarding the political structure of Australia with a direct link for members to their local MP. This may well encourage the voice of individuals , in addition to that of the organisation itself.

In England, following the Francis Report, the dismissal of whistleblowers continues. A hospital manager was dismissed for raising concerns about hospitals patients being locked in their rooms " children and pensioners were being restrained and locked in hospital cubicles for up to 12 hours without food or drink." (Bentley 2014). This was said to occur due to low staffing. The hospital is being investigated by the CQC, for this and other issues. Of relevance, the hospital is  a Foundation Trust. The government have no involvement in running FTs; further explained within this book.

Stroble et al (2014) discuss the effect on staff of whistleblowing or adverse events in care. Psychological trauma including suicide, was found to result based on a survey of 9 UK professional  regulators "There is no shortage of policy and guidance in the NHS on how to deal with stress, serious incidents and staff wellbeing, and employers provide a range of support, as do a number of other organisations. But it is unclear how easily accessible or effective the support is". (ibid).This study did however, consider only the NHS . Meanwhile whistleblowers in Uk continue to be attacked (Triggle 2014), cases of bullying and mismanagement are described within a "culture of fear" (patients First ibid). Of 70 cases (Patients First ) "In 79% of cases, the whistleblower had experienced bullying and in a fifth of cases the individual had run out of money or was unable to access legal advice, the dossier - which also included some Scottish cases - said.Again the article refers only to the NHS, situations may be worse within the private sector as this book discusses.Gagging orders on staff continue, the NMC has issues new guidelines, and a national whistleblower helpline has been commenced (ibid).The issue continues to be an international problem.

Kemble (2014) writes of a positive response from a care home company to whistleblowing within one of its care homes "The owner of Milford Manor care home in Salisbury has praised the bravery of whistleblowers whose evidence this week in court brought the conviction of a senior carer for mistreating elderly residents." As  a result the company Wessex care will now use CCTV in all of its 5 homes. Interesting the Director Mr Airey has experience in  child protection and social services.Credit also due to the home manager who investigated cases of abuse of residents in response to care assistants who reported it. The care assistant who abused the residents was described  as a "rogue carer"- atypical of the care home. Short staffing was offered as  a defense but the home owners stated this was not the case. As this book discusses, short staffing does not cause physical abuse.

Lintern (2014) states "A UK-wide private provider of nursing services must pay the legal costs of a whistleblowing nurse". An employment tribunal awarded the nurse more than £80,000 (ibid).Allied Healthcare had decided to replace nurses with care assistants for caring for disabled people and the nurse informed the Health Board  in Wales (ibid).Meanwhile the cost of taking one's case to  a tribunal has been increased (Doward 2014) which may prevent cases being heard anywhere.

"Whistleblowing" extends way beyond the practice area- the work of authors or campaigners may be blocked as discussed within this book. Does the attack or block upon whistle-blowers, reflect politico-social aims? Are many self-gaining -trying to protect their own role? An additional chapter is commenced below of people who have been ignored in this way.


Bentley P (2014) Despite the Government Vows to Protect Whistleblowers , NHS Boss Who spoke up against Locking up Patients is Sacked 15.3 Mailonline (Ack D Hazeldine twitter)

Doward J (2014) New Fees Lead To Drop In Employment Tribunal Cases 27.6

Kemble E (2014) Care Home Owner Praises Brave Whistleblowers  27.9 (ack Christina Taylor twitter)

Lintern S (2014) 'Hostile Private Provider' Must Pay Nurse Whistleblower's Legal Costs 7.10

Nightingale L (2013)

Stroble J, Madhock R, Panesar S, Carson-Stevens A, Cross H, Mcildowie B, Ward H (2014) How To Protect The 'Second Victim' Of Adverse Events 5.8 HSJ  (ack R Madhock twitter)

Triggle N (2014) NHS Whistleblowing 'Problems Persist' 22.9 (ack D Drew twitter)


Chapter 12 Whistleblowing

This is an interesting perspective that needs further research. The focus is upon "whistleblowing", which some regard as an inappropriate term to due "attacking connotations". As this book indicates, problems exist prior to whistleblowing. What is needed are staff of all levels and roles, who dare to challenge practice by questioning or making suggestions. Many are afraid to do this- fear ridicule, bullying, stepping outside "the box" or group. For example, when witnessing excess routine such as queues for baths, staff need the strength, assertion and support to be able to question . This may well involve re-education of all staff and attitude change .As this book suggests, some individuals may consider practices to be satisfactory that others do not. It may also be necessary, and particularly difficult, for student nurses to question practice. Education is needed involving discussion of actual situations and what to do scenarios One article which addresses the problem is (nursetogether.com2013). Of course there may also be more serious situations, causing death, such as medical treatments not done for which suggestions at the time  of changing practice  are inadequate. Nursing has traditionally been a hierarchical profession. When the stern matrons were in post, they were very efficient but few would dare to question them. This still has to change.

Reference (2013) 30.10 healthcare is waiting for Nursing professionals to speak their mind (ack to S Scheuermann for reference. LinkedIn)


Chapter 13 Ombudsman

The 4 UK regions each have  a different format of the ombudsman. Here are the equivalents  based on my own research contacting links in each of the regions and then clarifying with the body ;


Northern Ireland;

England – Health Ombudsman/Local Government Ombudsman.

Northern Ireland Ombudsman. The Northern Ireland Ombudsman can deal with complaints about: a government department or agency, local councils, health services, education services


In Scotland, Complaints may finally be raised with the Scottish Public health Service Ombudsman regarding NHS and Councils, for example but not private care services.


The Public Services Ombudsman in Wales,  will investigate some complaints regarding NHS patients  in  hospitals or NHS funded patients in private hospitals  and nursing homes. but similar to England, there are  criteria to meet. Private paying patients in hospital or care home, are expected to seek the advice of solicitors which may be expensive and stressful for many.


Despite the Ombudsman, there are differences in other agencies within the  4 regions. For example, All healthcare in Wales; private or NHS, is inspected by the Healthcare Inspectorate Wales. There are 7 local health boards who plan and deliver services . Community Health Councils still exist in Wales.CHCs aim to improve and monitor quality in NHS services. They are described as being independent- some are council members or known to the council (

(Dimon 2014)


In England, the health ombudsman has been "throwing complaints away" (Donnelly 2014), " it fully investigated less than 400 of 16,000 patient complaints made last year". Professor B Jarman commented "complaints should be treated like gold dust" due to lessons to be learned from them. The ombudsman say they have changed their approach, but as this book discusses, there is evidence of such problems in all countries for many years. Is the ombudsman indeed, a means to shifting problems on within the system?  The government do argue that such bodies are independent- but in reality, is this so?

Roberts (2014) announces "The NHS ombudsman - the independent service that investigates patients' complaints - is "wholly ineffective and failing families", warns a charity."-  this supports earlier references in this book eg Bokhari researched many countries , UK Health Committee (2011) declared a "complete overhaul" was needed p74. Issue raised by the Patients Association (ibid). New PA report (2014)


One example of  a more open , encouraging approach in Calrfornia (canhr) . Give an example of a simple form to give to people who wish to complain, simple outline of procedure, amongst other things such as individual review with the people concerned. Indicates again, similarities of issues between countries, and different approaches available.

More evidence of UK government's failure to accept responsibility for and regulate "independent bodies" (Newsome 2013). "Professions effectively regulate themselves" (ibid). "The Ombudsman refuses to investigate as long as the subordinate authority claims to be investigating"  (ibid).Freedom of investigation requests do not have to be answered by certain bodies since the FOI Act 2000/2005 is said not to apply. However some FOIs can be extremely difficult to obtain (updates to come- work in progess)

There are within UK, USA, Australia, as discussed in this book, a number of campaigning groups led by relatives or staff. Some of these groups are totally independent ie not linked to the government/ nursing agencies, in any way. These include in the UK;,

This assists you with freedom of information requests UK

Report  by Healthwatch England (Brimelow 2014) identifies the complaints procedure within care homes and NHS England, is too complicated with 70 bodies being involved in some cases. Hopefully this wil be addressed. As this book identifies, how people complain depends on how their care is paid for and who owns the establishment. There are similar problems regarding the complaints system, within the USA and Australia.

Whilst there has been some improvement in the way that complaints are  dealt with in the UK by the NHS (Triggle 2014), still only one quarter of 4000 surveyed were happy with the way their complaint was handled.The complaints process remains extremely difficult for people as Triggle states "Earlier this year, the patient watchdog produced a report showing that more than 70 organisations were involved in complaints handling in the NHS and social care systems."

MPs in Wales (bbc 2014) request patients in the private sector have the same rights as those in the NHS. This refers to the complaints system; "Calls have been made for private healthcare patients in Wales to have the same rights as those on the NHS."As this book discusses "Private patients cannot complain to the Public Services Ombudsman for Wales unless they have received treatment commissioned and funded by the NHS" (ibid). In Wales after consideration by the private company, " the complaint can be heard by an independent adjudication service, which which the association says is similar to the ombudsman process  (ibid). The article does state that in England there is  a recommendation for the Ombudsman to consider cases within the private sector- is this likely considering political aspects such as abdication of responsibility by the government and possible personal involvement of some MPs by way of investing?  The article also raises again the issues of what are rights, and who says what they are?


Raising complaints about healthcare as discussed in this book, is extremely difficult. Nightingale (2014) concludes based on literature analysis and experience, that regulatory bodies protect the establishments and politicians- not service users or complainant, "The Ombudsman (more accurate if called Ambushman) will close a case if the smallest of details are not submitted, and if the slightest inference is given that legal action is being considered, which, of course, could mean the Trust paying compensation "."Trusts have enormous influence with the GMC and NMC. If a Trust states it has ‘no problems’ with a doctor or nurse, the GMC and NMC will be unlikely to take the case forward" (Nightingale 2014). Beware they who whistleblow  or raise issues ! This suits NMC revalidation proposals as Nightingale states, when the employer validates the Registered nurse.

Thre number of complaints in the UK about the NHS including hospitals, GPs,dental services, and ambulances has increased 2013-2014 ( 2014). This may be due to greater public awareness of issues and the Francis Report. This could also be one reason why such cases have been kept out of the mainstream news in the past and some would argue, still are. "

In the year 2013-14 a total of 174,900 complaints were made about the NHS. It compared to 162,019 the previous year and 131,022 in the 2007-08 financial year. The majority of complaints - 34,400 - focused on inpatient hospital care" (ibid). However, many people still do not want to report poor care (Healthwatch England ibid) thus these figures could be "the tip of the iceberg" (ibid).Whilst more facts about how this survey was done are needed, "The body undertook a survey which suggested that there were 500,000 unreported cases of unsatisfactory patient care across the NHS in the past two years" (ibid).

Some evidence that PHSO England failed to investifate complaints that they really could have done eg case  raised by  James Titcombe ( 2014) "Mr James Titcombe made several complaints against the University Hospitals of Morecambe Bay NHS Foundation Trust, following the death of his baby in November 2008. Mr Titcombe's complaints related to the investigation into his baby's death and the way staff treated him and his wife. He took these complaints to PHSO in 2010, but they were not investigated. PHSO subsequently investigated and published a report in February 2014, upholding three out of four of the complaints made ".The phso "aims to investigate more complaints". No figure can be estimated regarding  a possible number of complaints- there should be no limit on this figure. "Dr Alex Brenninkmeijer, the National Ombudsman of the Netherlands, told us during our visit to the Netherlands that an ombudsman should look at all complaints that fall within its competence" (ibid).


Reports of poor care in Australia are usually witheld from the public (wikihospitals 2014) which may explain why there are few reports in the press online."This story will come as no surprise to those who are familiar with Australia’s intense secrecy over healthcare errors" (wikihospitals ). Wikihospitals discusses a case of  a Doctor who was addicted to drugs . Action was only taken against the doctor after he was reported to police following the death of  a second woman who died whilst with him on a "drug binge" (ibid).


BBCnews (2014) Private Healthcare Patients Should Have 'NHS Rights' 14.8

Brimelow A (2014) NHS Told to streamline 'complicated' complaints procedure 20.3

Dimon C (2014) Healthcare Complaints? We Have an Ombudsman

Donnelly L (2013) NHS Watchdog accused of throwing away complaints The Telegraph 3.2 (accessed 10.2.14) (2014)

Newsome B (2013) National Healthcare: How Not to manage it (part2/2) 26.9

Nightingale L (2014 ) Regulatory Sham 

Patients Association (2014)  ack phsothefacts

Roberts M (2014) NHS Ombudsman 'Failing Families'18.1

Triggle N (2014) NHS 'Falling Short on Complaints Handling' BBCnews 8.7


Chapter14 NMC

The NMC (Nursing and Midwifery Council) is the registration body for nurses in the UK. Registration bodies in the USA differ per state which affects educational requirements and codes of practice ( ). In Australia nurses are registered with the body Nursing and Midwifery Board Australia

Another report by the PSA (2014 nursingtimes ) concluding that NMC hearings are ineffective (ack S Lintern). Again, NMC hearings need to be less subjective and more independent. As this book discusses, the independence of the NMC from the government and major nursing bodies, is questionable.There may well be issues regarding this aspect in other countries, but evidence and reports of cases, are hard to find in order to analyse.

Nurses that are removed from the NMC register often return to the same ward to work as  a care assistant (Telegraph 2011). Indeed reasons for removal may vary from errors to abuse.


The NMC proposes  a method of revalidating nurse qualification in the UK. At present  a record pf continuing professional development is maintained but very few portfolios are sent for (Nightingale 2013 ). The new method will involve references from managers, peers and residents. This may well amount to "silencing whistleblowing" as anybody who raises issues may be ostracized and blocked in their career (Nightingale 2013). If nurse education, and education of overseas nurses is adequate, one may question the need to do this at all. Yet additional factors are implicated such as work policies and support from managers.


Recently  a case occurred involving two care assistants from overseas and the death of  a resident in a care home who fell from the hoist, to which she was inadequately fastened (Duell 2013). This was due to language difficulties of the carers and absence of training within the home. hence the registered manager is responsible.

‘There can also be issues with English as a second language. Some cultures are more questioning. Other cultures, if they are told to do something they will do it until they are told otherwise.’ (Health and Safety Executive in Duell). This further supports the analysis in this book concerning cultural attitudes , and adaptation of overseas nurses. It is unfair to put overseas staff in such positions.

The NMC is revising the code. There are issues with the present one such as work conflicts (Dimon 2014). The new draft version (nmc2014) does highlight the duty of reporting concerns, but  nurses and midwives may still  face difficulties of work conflicts. "It will not be the ultimate panacea". It would be interesting to consider this issue overseas- especially USA and Australia.


Dimon C (2014) The NMC Code- Who Are We Fooling?

Duell M (2013) (8.1) 
'Full of life' great-grandmother, 100, 'died from fractured skull after falling 5ft when foreign carers failed to properly strap her into hoist'

Lintern SW (2014) NMC made 'wrong decisions' on Mid Staffs Nurses 31.3

Nightingale L (2013) ‎ … (2014 ) The Revised Code. Draft Version July (ack phso-thefacts)

The Telegraph (2011) Untrained Healthcare Assistants Leave Patients Unfed , and In Pain Claims Nursing Watchdog

Chapter 15 Human Rights

A study conducted in nursing homes in Northern Irelnad concluded "This investigation has uncovered significant structural barriers to the implementation of the human rights of older people in nursing homes. Therefore, specific failings in relation to, for instance, the provision of help with personal care or eating and drinking are often matched by gaps and shortcomings in the overarching legal framework

and policy guidance, which is, at best, weak in its commitment to mainstream residents’ human rights" (NI Human Rights Commission 2012).The study focussed on 5 key aspects- medication, eating and drinking,personal care, quality of life, and restraint.Recall standards and regulatory bodies differ in Northern Ireland to England as this book discuses. The study involved interviews in 4 nursing homes (including those for the elderly mentally ill)  , and of members of  the public.Also analysis of records. An earlier report (2007) had focussed also on human rights in hospitals  (ibid). "It concludes that for older people to be afforded the dignity and human rights protections to which they are entitled, changes are required in the law and regulation. It calls on human rights principles to be made the foundation of the relevant laws, regulation and training" (ibid).

In the UK the there have been successful cases supported by the Human Rights Act  (Amnesty 2014). These include the separation of two people within care homes- one person  did not meet the criteria for residential care, as happens a lot (see this book). Chris Gayling presently proposes ceasing the Human Rights Act. "This was a clear breach of the couple's right to a family life as protected by the Human Rights Act, and a public campaign was launched to encourage social services to think again. As a result, Mrs Driscoll’s needs were re-assessed and the couple were reunited – setting a precedent for elderly couples to be kept together in the same care home" (Amnesty 2014).


Amnesty (2014)

Northern Ireland Human Rights Commission (2012) In Defence of Dignity March

Chapter 17 The Exploitation of Overseas Nurses

Latest figure of overseas nurses working in the UK obtained following FOI request by the RCN "The number of overseas nurses and midwives registering to work in the UK has grown by nearly 50% in the past year, latest figures have revealed" (Merrifield 2014). Sadly the article refers only to the NHS- most overseas nurses work in the private sector hospitals and care homes, many of which have  a permanent contract with overseas agencies to obtain a constant supply of nurses. As this book discusses, overseas nurses are "cheaper and complain less " (Duell  2013). They also may have fake certificates often which cannot be identified here, different training , and different attitudes as discussed. Bluntly, this figure does NOT mean there are not enough nurses seeking jobs within the UK. Of course the situation may also be regional. The figure needed is the true figure of newly qualified nurses UK who cannot get jobs as  nurses within the UK  (Nightingale gives 2 thirds as the figure). Nobody has this figure at present. The importance of this issue is being lost amongst propaganda. Remember also the affiliations of the RCN to conflicting associations (Nightingale 2014).Again none of these issues are confined to the UK.

These issues are also discussed above (ch 8).

Stewart J  (2014) "Thousands of nursing graduates are unable to find work in Australian hospitals, according to the nurses' union .(ANFM)

Traditionally Australian nurses have been in high demand, but unions say that large numbers of foreign workers on 457 visas are taking their place. " Out of 8000 new nurses - 3000 are said not to be able to find  a post as a nurse in Australia (ibid). Similar to our points ""Is it just that they are seeking experienced nurses, or are they seeking nurses who will form a more compliant workforce, totally dependent on their employer for their ability to stay in Australia?" (ibid).



Merrifield N (2014) Overseas Nurse Recruitment 'Jumps Nearly  50% in  a Year'  (ack D Mulikin twitter)

Stewart (2014)



Additional Chapter

To add specific chapter regarding Falsified Records- see discussions above.

Whistleblowers- national (not practice level);

In UK there are several examples of people who have attempted to generate change, either alone or in groups.

Will Powell has achieved much on behalf of his son Robbie, but not without being blocked and accused as this letter indicates

A common problem is failure of agencies  or  individuals to respond to emails or letters.

CuretheNHS -Julie Bailey endured horrific attacks

Researchers- work often discredited eg

Authors-excluded from mainstream publications-

Conference speakers-


Treatment generates Profit
Any treatment provided whether NHS or private or charity, is bought from a private supplier. This includes dressings or medication. Blood and blood products may also be included. Lenin Nightingale describes well the factors involved in this  “The UK government sold an 80% stake in the NHS blood supply service in 2013 to Bain Capital, a private equity company which uses leveraged buyouts – borrowing large amounts of money to buy a company, then placing this debt on the company itself”. “Germany allows people to give plasma 38 times a year, compared with 104 in the United States. Why might the former figure be the more appropriate? “There are 15 collection facilities straddling the USA/Mexico border, where the poor are connected to machines that suck the liquid part of their blood (plasma) from their veins. The USA is one of the few countries that allow donors to be paid, and, even here, donors are told they are being paid for their time, not their plasma, which is a ‘donation. The USA supplies more than hlaf of the world’s blood plasma” (Nightingale). “Corporations are also involved in the ‘egg donation’ industry, which extracts eggs from poor, young females, reselling them for use in commercial production of children” (Nightingale 2014) Apart from supplier level, there are the private companies who manufacture such items.

Clinical trials are often undertaken unethically concerning drugs. This has happened in history with such as TB vaccine (Webe 2013) and the Nazis. Krishnan and Politzer (2012) describe  a case in India “A hospital in Indore has been able to get away with unethical medical trials in which 32 people have died over five years, according to the state government. This despite several investigations, a state government ban and Supreme Court strictures—a classic example of the lawless nature of the clinical trial business in India.” “Besides these cases, 1,833 children from the Chacha Nehru Bal Chikitsalaya (the paediatric hospital affiliated with MGM Medical College) and 233 mentally ill patients had been enrolled in clinical trials without any consent, according to documents submitted to the Supreme Court.” (ibid).

Of course despite people will accept offers of money for their organs or offers of cheap drugs.

There has been  a reliance on drug treatment certainly within psychiatry (Maconachi 2007), "psychiatry  is big business". "Over six million children in the US are on drugs that control the symptoms of so-called Attention Deficit Disorder - ADD"  (ibid)." the actual clinical methods employed for diagnosis are bogus to non-existent" (ibid). "They merely mask symptoms and control people who have been labeled as "schizophrenic", "psychotic" or "hyper" (ibid). There are other factors such as nutrition and society. Alternative theories that support this such as D Laing are analysed by Lenin Nightingale (2014) and there will be other authors.

Earlier in the USA (1946-1948) people including prisoners, prostitutes, and the mentally ill, were deliberately infected with syphilis and other sexually transmitted diseases (Gautemala- Obama accepts about 83 people died as  a result and scientists knew that they were violating ethical rules)(Donaldson James 2011).

Further Doctors in America  are offered or given bonuses by manufacturers  for using certain medications , including free meals and speaking engagements (Lamb 2012). Of course this also applies to other countries.
There have been several claims against drug companies for side effects or even deaths of individuals. Some have resulted in compensation and drug alterations . Others remain disputed. The difficulty is knowing if the effect was a direct result of taking the medication.
Yet there have been falsified research results (canceractive). Research for drugs is undertaken by the company who actually manufactures the drug hence they have an ulterior motive to ensure that  it works. “conflicts of interest may cause some researchers to report results that are biased to be favorable to Big Pharma companies” (Baker 2009. There have been recent examples in the press.
 Consider Ebola . There has been little focus on developing  a vaccine due to the low demand for it and inability of Africa to pay for it (Dyer 2014).

Rosenthal (2014) discusses the rapid increase in the price of some drugs such as digoxin , by drug companies. "For patients, that meant the prices at pharmacies often tripled from last October to this June" (ibid).In the USA of course, patients have to pay the price of the drug " one patient did not fill her prescription because it would have cost her $1.60 per pill, and that she ended up in intensive care" (ibid). Even the price of vaccines is affected "Like many vaccines, Prevnar requires multiple jabs. Each shot is priced at $136, and most states require children to get four doses before entering day care or preschool " (Rosenthal 2014). In the case of digoxin there were no explanations for the price increase apart from "financial rewards"  (ibid)

Ornstein  et al (2014) announce "On Tuesday, the federal government is expected to release details of payments to doctors by every pharmaceutical and medical device manufacturer in the country". Doctors  and others ,  according to the Affordable Care Act 2010 must disclose  additional payments such as public speaking (ibid). Ornstein et al have gathered some data from drug companies and present a useful chart of the estimated number of people who were paid by drug companies eg Pfizer was said to be 142,600 people in 2013  (ibid).

Reuters (2014) also discusses this issue "U.S. doctors and teaching hospitals received $3.5 billion from pharmaceutical companies and medical device makers in the last five months of 2013, according to the most extensive data trove on such payments ever made public". Payments included speaking, meals , entertainment, and research grants (ibid).

BBCnews (2014) announce GPs  in England  are to be given £55 for diagnosing somebody with dementia. "Fewer than half of the 800,000 people in the UK who are estimated to have dementia have been formally diagnosed" (ibid). Is the aim to validate the figure? Many people with dementia are wrongly diagnosed , it could well be symptoms of another condition ( Pulse 2014 ).  Testing  a patient's memory is an inadequate diagnosis of dementia. There have been cases as this book discusses, where people have been wrongly said to have dementia - given as a "reason" for lack of capacity thus being maintained within care homes for example. GPs do receive payments for many things such as raised cholesterol- all encouraging the use of medication and profit for drug companies. Many would debate the benefit of statins for example. The Patient's Association is speaking out against this payment.

 This case illustrates these points well (Willey 2014) "She was forced to sell her house to pay for an 18-month stay in a care home – only to find that doctors had wrongly diagnosed Alzheimer’s.Mrs Hill, 88, was told she had it and needed round-the-clock attention. She agreed to put her house in Plymouth, Devon, on the market so she could move into care." "A different doctor diagnosed Mrs Hill with mild cognitive impairment from which patients can make a full recovery." Not all relatives can obtain a second opinion.

Similar difficulties exist regarding defining dementia within other countries eg Denmark ( 2014) . In a survey of 200 patients, 86% were found to have been correctly diagnosed with dementia.

Not all GPs UK support the governments proposal to pay £55 per diagnosis (Brunet 2014) -encourages GPs to refuse to do this saying "patients cannot opt out of  a diagnosis". It may even prevent people from attending the GP This proposal could well be against the GMC code of conduct. Stirling (2013) describes possible effects of this action including increased waiting times at memory clinics."there seems to be a political drive to push up prevalence levels for the sake of numbers and the care of patients suffers consequently as expectations of treatments do not actually match the results of the treatments that are currently available" (ibid).

NICE  is the body which determines which drugs can and cannot be used by the NHS, Here is one example of conflict of interest "They warned that eight out of the 12 members of the Nice panel which produced the guidelines had “direct financial ties” to firms which manufacture statins". Statins are prescribed to reduce cholesterol to prevent such as strokes (Malnick, Donnelly 2014). The issue has been raised by Doctors and academics (ibid).
In effect, it is not simply care and concern that drives actions of the majority of people.


Several cases of fraud by Doctors  in the USA concerning Medicare and Medicaid have been highlighted (leftfutures 2014). This is not confined to private owned services, Triggle (2014) discusses the NHS involving " non-payment of prescription charges by patients, medical professionals claiming for work they have not done and overcharging by contractors". Fraud costs the NHS £5bn  a year and does not only refer to hospitals .Leftfutures  reports that the US healthcare system is "a magnet for thieves" due to fraud of Medicare and Medicaid by Doctors ,pharmacies, and patients. Treatment is claimed for that has not been done such as prescriptions or visits. There have been cases in the UK of care home managers (nurses or senior care assistants) fraudulently taking money from residents or the care home  and similar within the community.

Such fraud in the USA also includes nurses and social workers (Kennedy,Yost 2012), "Federal authorities charged 107 doctors, nurses and social workers in seven cities with Medicare fraud Wednesday in a nationwide crackdown on unrelated scams that allegedly billed the taxpayer-funded program of $452 million – the highest dollar amount in a single Medicare bust in U.S. history" Miami.

This does not only refer to hospitals but also community mental health centres, again for treatment not given.

Also in the Philippines (Triten 2011) . India (drMalpani 2014).Sweden (Jesilow 2012), "Frauds committed by recipients of public insurance and providers of health care are stealing millions of kronor from Swedish taxpayers each year". Jesilow explains that fraud may increase with further privatization in Sweden.

Linking this to the original aim of this book, to explore why poor care continues, is fraud  a result of aims for self-gain as promoted by society and politics? Does this also return the discussion to "one's conscience"?



Baker SL (2009) Cancer Research Published in Respected Journals Biased By Medical Industry Money may22

 Canceractive Another Cancer Researcher Tells of Falsified rug Research

bbcnews GPs to be Paid £55 for each dementia diagnosis

Brunet M (2014) Cash For Diagnosis? Just Say No 22.10

Donaldson James (2011) Syphilis Experiments Shock , But So Do Third World Drug Trials

DrMalpani (2014) Healthcare Fraud 15.6

Dyer G (2014) No Profit in Ebola Vaccine For Poor Africans

Jesilow P (2012) Is Sweden Doomed To Repeat U.S. Errors?

Kennedy K, Yost P (2012) Medical Fraud Crackdown : 100 Doctors, Nurses, and Social Workers Charged in Historic Bust Huffington 5.2

Krishnan V, Politzer M (2012) Clinical Trials :Regulating Chaos 12.10

Lamb J O  Doctors Face Dilemma Over Compensation From Drug Companies

leftfutures (2014) Is this The Kind of US Healthcare System The UK Is Headed For? (ack M Meacher twitter)

Maconachy A (2007) The Dangers of Psychiatry  ack Rosemary Cantwell

Malnick E, Donnelly L (2014) MPs Probe Claims of NHS Drugs Conflicts of Interest 22.10 ack Gerry twitter

Nightingale L (2014 )

Nightingale L (2014)

Ornstein C, Grochowski Jones J,Sagara E (2014) What We;'re Learning About drug Company payments To Doctors 29.9 ack P Gordon twitter)

Pulse (2013) Dementia DES Will Result in Widespread Misdiagnosis, Expert Claims

Reuters (2014) Doctors and Hospitals Raking in Billions From Big Pharma, Huge Data Trove Reveals 30.9 ack Rosemary Cantwell)

Rosenthal E (2014) Rapid Price Increases For Some Generic Drugs Catch Users By Surprise 8.7 (ack paying till it hurts facebook)

Rosenthal E (2014) The price of Prevention: Vaccine Costs Are Soaring 2.7 newyorktimes

Stirling A  (2014) GPs Hit By Widespread Complaints From patients 'Unhappy' Over Dementia Screening 22.10

Triggle N (2014) NHS Fraud and Error 'Costing The NHS £7bn  a year' 24.3

Tritten TJ (2011) Tricare Scrapping Troubled System in Philippines To Address Fraud, Military Retiree Care 28,11

Webe B (2013) TB Vaccine Tested on Aboriginals, But Living Conditions Not Fixed The Canadian Press

Willey J (2014) Dangers of Dementia Misdiagnosis Highlighted By 88 Year Old Winnie express.CO.UK 22.10

Additional chapter

Respect for the dead


Even the dead have become commodities to some. Has  a dead person seemingly   lost his or her “use” to society?

There are cases where dead patients remain on a hospital ward or on a corridor for several hours in the UK . There are reports of this spanning between 2006 and 2011 on google/duckduckgo . Reasons include lack of availability of  a porter to move the body or  a  Doctor to certify the death.  This has caused  a great deal of distress for staff, other patients, visitors, and relatives.

More widely in society this is reflected in the neglect of cemeteries by the public. Weiner (2013) explains this is related to profit of the cemeteries when discussing neglect of Jewish cemeteries in New York. The communities often do try to maintain them. There are also several groups that will do so - 

Many cemeteries are subject to vandalism. This site provides images of neglected cemeteries in many countries including the UK 

Again a case of profit overrides care.

If a person is unable to pay for the Funeral in the UK they are undertaken according to section p46 of the Public Health Act .This involves a communal grave (Bingham 2014) . As Bingham discusses “according to a new study, paupers’ burials are making an unlikely comeback as families exploit a legal loophole to save thousands of pounds on funeral costs.”

Gentleman (2014) explains paupers funerals in the UK are increasing as families cannot afford funeral costs which may be from £2500 upwards. Many are opting to do the funeral themselves by delivering the coffin in their own care to the crematorium (ibid). There is  a funeral grant of £700 but 50% who apply for this are rejected (ibid).There are cases where people donate money to pay for a peron's funeral (ibid).The thought of being unable to pay for  a funeral is extremely stressful for families and old people-many still regard a "paupers funeral" as indignifying.The Natural Death Centre does offer support and advice (ibid). Surely funerals ought not to be so profit making? Will there be an increase in burials in the back garden?

Of course there are cultural factors to the treatment of the dead which varies per country for example  China (

During times of great plague or disasters, it may not have been possible to maintain such dignity as with mass graves for example.

Sadly there are cases in hospital when patients die alone , whether expected or not (Beighton 2013). Often this is due to staff shortages and distresses  staff greatly. There are groups of volunteers within the USA who exist to sit with patients who are dying (Diaz 2014) and there may be local groups in other countries, especially linked to hospices.

If we cannot respect the dead and dying , what do we have left?

Ack to twitter discussion (Karen Armstrong)  for issue on wards.

Additional chapter Campaigners

 In all countries there are groups or individuials who do try to improve situations. The affiliations of some of these are questionable as discussed.

Yet without campaigners little would be achieved.Whilst some campaigners begin alone, or in small groups, they are often over-taken by larger associations who may have vested interests or political links; they then become part of the problem.

Public Concern at Work have assisted many individuals with care homes and hospitals. One case describes  a care home in which the   deputy manager was supported to report sexual abuse of residents by the owner  "If another incident occurred, we advised her to contact us immediately and take care to keep any supporting evidence. We checked with the Social Services Inspectorate who confirmed our advice was sensible" (ibid). Another case where cameras would have been beneficial- " with a clean swab, took a specimen from the lady’s mouth". The residents were blind and suffered from dementia.

Noticeably in the UK, Fiona Philips TV presenter regarding care in care homes and dementia .

curethenhs 2007  lead by Julie Bailey in response to poor care received by her mother in Mid Staffordshire .NHS hospital.

Such groups as phsothefacts challenging primarily the PHSO.

Patients First- nurses, doctors, managers , and staff who are concerned about care

Individual campaigners who campaign alone unconnected to groups include Will Powell (Davies 2006) and Toms Anguish (twitter).Being alone is advantageous in many ways- one is unaffected by politics or aspirations of others and is personally fuelled to  achieve improvements. However, it is rather more difficult to be heard, especially so before social media arose. Even now letters and emails can go unanswered, and twitter or facebook can be censored. "Fifteen years ago, Will Powell saw his 10-year-old son die. Within days, he began to suspect that doctors who had looked after the boy had been negligent. He filed a complaint. Within months, he began to suspect that somebody was tampering with his son's medical records. He filed more complaints, and spent 15 years fighting for the truth. Now, finally, he has it - and he was right" (ibid). The lack of help available to Will Powell was phenomenol including coroners, police, and MPs.Eventually he took the case to the EU court of human rights- no easy task.Several statements were not gathered, records went missing, and false records were made.The time limit for investigations should be abolished, as the author states-  "  none of them should be prosecuted because too much time had passed" (ibid).

There is  a need for such "independent groups" to campaign to ensure their voices are heard. One needs to question what other means there is of obtaining information? Not everybody can afford  a solicitor.

In the UK, an individual or group can ask for a FOI (Freedom Of Information request) and public bodies such as the NHS are obliged to respond within a time limit. It appears that bodies excluded from this requirement include the RCN. FOIs are now displayed on the web as requests and responses. FOIs may refer to such as statistics or policies for example. However, they may be unanswered if the request is deemed to oppose public interest or facts are unavailable.This is often  a very frustrating process for people. There are several groups and individuals exploring the FOI process, and many will offer advice such as FOI directory .

Toms Anguish (J Brooks)  made 25 FOIs. Of these 12 were refused, some were overdue, some were given a limited reply, and some were successful. Here is an example of one which illustrates the frustration and difficulty faced by individuals who request information

J Brooks 2011 "I have written to you on several occassions asking for you to explain contradictory statements that you have made to me about different matters to do with your organisation."

Burgess (2014) "Police are routinely being called to restrain dementia patients in care homes because poorly trained staff cannot cope, it emerged last night". This information followed an FOI request. Police officers have attended residential homes with tazers and riot gear but have been able to negotiate on arrival. One wanders what the restraint was for? Was it for safety of the resident such as falling or was it for the safety of others, or was it to restrict  residents from  wandering outside?  Consider this with the misdiagnosis of dementia- as discussed.



Of course campaigning as an individual, or as a group, is not an easy task whether member of the public or staff. Attacks may be similar to those against  whistleblowers. Considering history, any individual who wrote from  a different perspective such as Freud, Darwin, or David Icke, endured attacks and ridicule by the masses. This book discuses factors that may contribute towards this reaction. In addition many have  a competitive nature fuelled by politics and society, which particularly affects writers and researchers.

Australia - As in the UK there are national groups but how politically influenced they are is questionable- highlights cases of error and abuse with hospitals and care homes in Australia. They offer advice to people who need to complain and regarding other matters,  and state that they are not government funded.The Foundation was established in 1996 by the family of June Long.


 In addition to campaigning groups there are groups established by individuals, to assist people or services. For example people who comfort dying patients in hospices, or visit older people. Without them, many would be struggling.




Beighton H (2013) Barry Was Left To Die Alone After Appalling Care

Bingham J (2014)  Pauper’s Funerals Making Comeback AS Families Exploit Loophole To Save Funeral Costs The Telegraph 21.1

Burgess M (2014) FOI reveals Police routinely called to Restrain Dementia patients in 'Deeply Concerning Trend ' 11.11 ack Foi directory twitter

Davies N (2006) Fatal Flaws 4.1 (ack W Powell twitter)

Diaz J (2014) No One Dies Alone: Austin Program Ensures Patients Don't Face Death By Themselves 5.8

Gentleman A (2014) The Return of the Pauper's Funeral To Austerity Britain 20.10 ack greenburials twitter

Hitchens N (2011) Dead Bodies Left on Darent Valley Ward  20.1

Hull L (2006) Scandal Of Dead Bodies  Left On Hospital Ward in Funding Crisis 27.6

Weiner J (2013) Lacking Long-Term Plans, Many U.S Jewish cemeteries in Neglect  19.12

Additional cover-ups

Many people are realising that poor care has not been the only cover-up. Certainly within the UK during the last 3 years, many cover -ups have surfaced. These are major situations that have been kept out of the public eye, or truth distorted, by politicians or they who are connected to them. Whilst some have been identified earlier, it will be useful to provide some links here for people to investigate further.

International issues involve fracking and fluoride (Nightingale 2014 and other authors).

The need for , and cause of war is another one (see Veterans today or David Icke or Voltairenews for example).

Information about vaccines and on going research linking them to autism  (Moulden 2013 and others)

Vaccines- Mercola 2014 in RINF lists cases highlighted by whistleblowers including accusations of falsified research and questions about autism or the effectiveness of certain vaccines. Meanwhile in the USA healthcare workers have been fired for refusing to have  a flu vaccine (ibid).One nurse union is fighting this enforcement of vaccines  on behalf of nurses (ibid).

Paedophilia certainly within religious organisations, by nuns or priests, within children's homes, News of this has surfaced within USA. Australia, UK and has occurred for many years (eg Pearlman 2014,4bitnews,Donnelley 2014 in Icke,

HSBC bank (Mr ethical on twitter) and several other banks (Max Keiser)

In the USA, the cause of 9/11 is being debated (David Icke .and others)

In UK, "mad cow disease" was caused by infected sheep being fed to cattle. The UK govt were the only country to allow this despite advice not to do so (Manger 2013)

Horsemeat in beef products (Lawrence 2014)

GM modified crops David Icke, RINF, 4bitnews and others . (Cummins 2014)

Medication and side effects. It is however, difficult to prove at times. Also falsified research by drug companies (Baker 2009).Lack of consent for drug testing (Donaldson 2011 )

Imported blood plasma and risks of infection (Nightingale 2014).

Stolen body parts  (Nightingale 2014 and others)

Distorted figures of the number of unemployed USA/ UK. Many are unable to claim benefits or are on zero hour contracts which may mean no paid work for weeks.(Shedlock 2013)

Censorship eg computers and surveillance (Icke 2014,  RINF 2014, Nightingale 2014 and others) see eg  Julian Assange

Fake certificates affecting all jobs eg nursing  (Dimon 2014, Nightingale 2014)

Stolen children eg aborigines Australia (greenleft weekly).

Child sacrifice (Beforeitsnews 2014). “Further cooperation with the police is expected, included in taking down executives of the Cargill corporation in Minneapolis who are engaged in child trafficking and killing” Annett indicated. Police in three European nations were working directly with the ITCCS to arrest global elites who feed children into Ninth Circle Satanic Child Sacrifices and pedophilia. Reverend Annett acts as North American Field Secretary for the ICLCJ Court and International Tribunal into Crimes of Church and State which has been prosecuting Ninth Circle cases since 2010. Official sources.see also David Icke.

Political prisoners (Harding 2014). There are similar cases in many other countries.

Torture Nightingale 2014,

Ebola - Snyder (2014) in Icke puts it bluntly  following the arrival of ebola virus within Dallas "I can understand the need to keep the public calm, but why don't these officials just tell us the truth?" "Air travel between the United States and the countries of Liberia, Guinea and Sierra Leone should have been totally shut down except for absolutely essential personnel but it wasn't " (ibid).


Hillsborough UK- people at the football match were accused of having been drunk and caused the problem .eg Brown 2013

Noticeably most of these issues have not appeared in mainstream news.

News in general- international (Packer2014) "Between 2002 and 2012, according to the Committee to Protect Journalists (C.P.J.), five hundred and six journalists were killed worldwide, as opposed to three hundred and ninety in the previous decade "; we talk about restricted publication but what is it ? International censorship,Simons (ibid) "Deluged with data, we are blind to the larger reality,” Indeed  few will believe if NOT published in mainstream press.

It would seem that such cover ups are part of  a political ploy to maintain control of the public. Some may argue it is to prevent public panic.It could also be to raise profits for big businesses. Do cover ups ensure votes for politicians from the unknowing public  or businesses who profit?

References and useful links

Baker SL (2009) Cancer Research Published in Respected Journals Biased By Medical Industry Money may22

 Canceractive Another Cancer Researcher Tells of Falsified rug Research


Brown J (2013)

Cameron S (2014)

Cummins R (2014) Monsanto

Curtin E (2014)

Donaldson James (2011) Syphilis Experiments Shock , But So Do Third World Drug Trials

Donnelley P (2014) in Icke

Dimon C (2014)

Gillard M (2012) Untouchables



Harding L (2014)

Hayes S

Icke D includes Ponsford (2014) Censorship

Icke D (2014) Includes ZenGardner 9/11

Lawrence F (2014)

Lewis JE The Mammoth Book of Cover-Ups

Manger  M (2013)

Max Keiser

Mercola Dr (2014) What Whistleblowers Tell Us About Vaccine Safety and Effectiveness 7.10 in

Morris N (2014) NHS outsourcing contracts

Mr Ethical

Nightingale L (2014)

Packer G (2014) Why the Press is Less Free Today 13.11 (ack F Bajak twitter)

RINF  (2014)

Shedlock M (2013) Jobless figures

 Snyder M (2014) in Icke censorship

Pearlman (2014)





In time many of these links will "disappear"





Finding news reports from all countries regarding good and bad care is not easy. It could well be that such information is censored and kept out of mainstream news which further supports political involvement.

As far back as 1930/1961 several authors were writing about political aims for one ruling government or  a new world order – Such work is not commonly available which says it all. (eg Orwell, Huxley, Kwame Nkumah )

Politics and nursing itself is  little discussed subject, in particular neoliberalsim or neo- colonialism ( How many nurses in the UK have heard of Horton’s work regarding neoliberalism and healthcare  in Australia for example?

Finding research projects is easier when one has access to university data bases and interlibrary loans. However we have compiled  a list for people such as ourselves. Research projects may also be biased, dependent on who has funded the project and available literature. How many researchers will search and use the information that is now available with blogs for example?

A major underlying issue to all problems is one’s reason d’etre- many seek and need  a job at all costs, many fear becoming an outcast. Surely it is time the outcasts united and ceased competing ? Politicians do aim to “divide to rule”- it is far easier to control many separate groups than  one huge group which may overthrow them.

Useful groups / webs:

Correct on 28.9.14

Welcome any  additions!


Useful webs;

UK:  Iceland



USA  useful references refugees and immigrants worldwide . Healthcare.

Australia; NSW rights of old people  useful info and resources USA







Alternative news;