I like to think I’ve kept my emotions in check pretty well for the past couple of months. Unfortunately that went right out of the window at the end of last week.
In general through this crisis, I’ve felt that the ‘system’ – politicians, civil servants and all those of us delivering care – have worked together better than I originally thought possible. It is, at long last, clear that the social care sector is high up in government thinking. I fear the consequences of the Coronavirus Act but applaud the intent behind the Social Care Action Plan.
But last week two things occurred that made me want to beat the wall with frustration. Do Not Attempt Resuscitation (DNAR) notices, and FPPE. (And yes the F does mean what you think.)
There was a lot of media noise at the start of this crisis about doctors not wanting to play God, not wanting to make those impossibly awful decisions about how to allocate scarce ventilators. Well I’m sorry, but some doctors clearly do.
Those doctors who do are, without notification or consultation with the person, their family or care provider, appending DNAR notices to people’s medical records.
It is both hospital doctors and GPs who are choosing to ignore the provisions of the Mental Capacity Act and what is very clear guidance. This is not a new problem – I know some families reading this will have in years gone by rebuffed doctors suggesting their child should have a DNAR notice – but it seems coronavirus has brought the issue into sharp relief.
Dimensions supports 3500 people and at time of writing I am aware of five who have had a DNAR inappropriately added to their medical records. Clearly the vast majority of doctors are therefore exempt from the criticism above. But one person is one too many, and other providers report similar issues. We state our beliefs here.
I’ve had to ask my colleagues who – let’s be clear – are juggling a lot of competing priorities, to recheck the medical records of the people they support in case there are any more nasty surprises lurking amongst the forms and paperwork. If any are found we will challenge, we will raise official complaints, we will issue FOI requests and we will signpost legal support such as Access Social Care. My view is simple – those few doctors who place DNARs on patients in such a cavalier manner shouldn’t be practicing.
In order to adhere to new Public Health England (PHE) guidance last week, Dimensions will now be kitting all our frontline colleagues out with gloves, aprons and masks. We expect our spend on PPE to go up 10-fold – from around £40k to potentially £400k per month. As I write this I am expecting this difference to be funded. It’s frustrating because the latest PHE guidance is unhelpful and will make things worse, not better:
It is guidance designed for large care homes where Covid-19 has been running rampant and domiciliary care where short visits to many peoples’ homes are the order of the day. It is not appropriate for the vast majority of the support that Dimensions provides – support for individuals or a small number of people living in their own homes.
You see, for Dimensions, coronavirus is relatively well managed. As I reported last week we are not seeing large numbers of people dying; the total has not risen for some time and amongst these few, several contracted it whilst in hospital for everyday health provision.
Our approach to PPE has been to ask colleagues to wear it following an individual risk assessment. This, crucially, ensures my colleagues continue to think and work in a risk based, person-centred way. It ensures we retain accountability for all our decisions in respect of how we support individuals to stay fit and well over the long term. When PHE issued the further ‘new’ guidance last week, I think it also assumed accountability for the outcomes of this directive.
Outcomes that are, frankly, unlikely to improve on where we were.
As with all challenging behaviour, this is just a form of communication. The person is trying to communicate things like ‘I can’t recognise you now. I’m scared. I need to be able to see your face to know who you are.’ Our behaviour support team has prepared some really helpful guidance for teams facing these sorts of challenges which I am pleased to share widely. Find it here.
If I’m a support worker being told on the one hand that I must wear PPE to stay safe, and on the other unable to wear that PPE because of a challenging response from the person I support, how am I going to react? My colleagues have been nothing short of heroic throughout this crisis. The new guidance puts real obstacles in their way and makes their critical work harder.
We cannot ignore or circumvent the PHE guidance. Whilst some local authorities would be content for us to retain our successful risk-based approach, many others are adamant that we must follow the guidance. And it would be patently wrong to set different rules for our colleagues based solely on their postcode.
PHE guidance has already changed five times in the past few weeks. One more wouldn’t hurt. Come on Public Health England @PHE_uk. Give us back our accountability. Let us keep the people we support and our colleagues safe in the only good way we know: through risk based person-centred decisions.