The fall in nursing numbers is a complete disaster

Without swift work to rectify this problem, patient care will suffer.

Following recent reports regarding a significant rise in emergency hospital admissions and higher patient mortality rates over the weekend due to a lack of senior doctors, we are now faced with the abysmal fact of fewer training nurses. Research by Nursing Times (NT) earlier this month revealed that nurse training places have been cut by more than 2,500 in the past three years. Professor David Green, Vice Chancellor and Chief Executive of the University of Worcester commented: "We are heading straight for a national disaster in two to three years’ time." Worse still, Strategic Health Authority figures obtained by NT showed that there were over two thousand more nurses opting to work in a community based setting as opposed to acute care.   

During my time in the NHS I have worked in primary and secondary care with the latter including time spent in acute medical, high dependency and intensive care environments. And I have witnessed first-hand the considerable strain placed on the nursing profession. In an acute medical setting for example, a nurse would be typically responsible for at least four to six patients, sometimes even more. And in the acute setting, a patient’s clinical state can change at any moment. As doctors, following initial patient assessment, we put plans in place from a management perspective to ensure recovery. But due to large patient numbers and demands from outpatient clinics it is difficult to be on the shop floor monitoring each patient around the clock - a sad fact but unfortunately true.

In a high dependency or intensive care setting, the situation however is very different. Doctors are always present and patients benefit from one to one nursing allowing for effective patient assessment. You may argue that these types of patients obviously need a more advanced and rigid monitoring regime and you are probably right. But ward patients also rely heavily on nurses to be their eyes and ears, alerting doctors to any concern they or of course the nurse may have.

An afternoon ward based scenario to help illustrate my point; a four patient bay being manned by one nurse.

Patient A has been admitted with chest pain which initially settled but has now recurred and is more severe in nature. The nurse must do a new set of observations, namely blood pressure, heart rate and oxygen saturations, as well as an electrocardiogram (ECG), give pain relief which has been previously prescribed and alert the doctor responsible for that patient about the change in clinical state.

Patient B, a chronic alcoholic admitted following an alcohol binge, starts to vomit large amounts of blood. He feels faint, his blood pressure is falling and he is at risk of cardio respiratory arrest. The nurse, in addition to recording new observations, will need to insert a cannula and start intravenous fluids if the doctor responsible for this patient is busy and unable to reach the patient straight away.

Patient C has been admitted with renal failure due to not eating and drinking. He has a history of severe depression and is refusing to take his medication. He has been referred to the on call psychiatrist but while waiting for a review is threatening to kill himself and other patients on the ward.

And Patient D, who has been admitted following a fall at home but is now suitable for discharge. He is becoming frustrated by the time it has taken to receive his discharge paperwork and medications. It has been two hours now and he wants to make an urgent complaint about the care he has received, or lack of, to the Patient Advice and Liaison Service (PALS).

You may find it hard to believe but the above ward scenario is certainly not far from the truth.

Not only are nurses expected to respond to changing patient conditions they are also responsible for patients’ personal needs, administering appropriate medication, referring patients to other multidisciplinary staff such as a physiotherapist or occupational therapist and for facilitating discharge to name but a few.

With falling nursing numbers, the government should take heed and put concrete plans in place to ensure this situation is rectified and done so quickly. The workforce is already stretched and I for one fail to see how patient care will not be grossly affected.

Neel Sharma is a Medical Doctor and Honorary Clinical Lecturer at the Centre for Medical Education, Barts and the London School of Medicine and Dentistry

Great Ormond Street Hospital nurses perform during the Olympic opening ceremony. Photograph: Getty Images
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How to end the Gulf stand off? The West should tell Qatar to reform its foreign policy

Former defence secretary Geoff Hoon on the unfolding crisis in the Gulf. 

Only one group stands to benefit from a continuation of the crisis in Gulf: The Quartet, as they are now being called. Last week, The United Arab Emirates foreign minister tweeted that Qatar and its Gulf Cooperation Council neighbours are heading for a "long estrangement". We should take him at his word.

The European political establishment has been quick to dismiss the boycott by Saudi Arabia, the UAE, Bahrain and Egypt as naïve, and a strategic mistake. The received wisdom now is that they have acted impulsively, and that any payoff will be inescapably pyrrhic. I’m not so sure.

Another view: Qatar is determined to stand up to its Gulf neighbours

Jean-Yves Le Drian, France's foreign minister, was in the region over the weekend to see if he could relay some of his boss’s diplomatic momentum. He has offered to help mediate with Kuwait, clearly in the belief that this is the perfect opportunity to elevate France back to the top table. But if President Emmanuel Macron thinks this one will be as straightforward as a Donald Trump handshake, he should know that European charm doesn’t function as well in the 45 degree desert heat (even if some people call him the Sun King).

Western mediation has so far proceeded on the assumption that both sides privately know they will suffer if this conflict drags on. The US secretary of state Rex Tillerson judged that a Qatari commitment to further counter-terrorism measures might provide sufficient justification for a noble reversal. But he perhaps underestimates the seriousness of the challenge being made to Qatar. This is not some poorly-judged attempt to steal a quick diplomatic win over an inferior neighbour.

Qatar’s foreign policy is of direct and existential concern to the other governments in the Gulf. They will not let Qatar off the hook. And even more than that, why should they? Qatar has enormous diplomatic and commercial clout for its size, but that would evaporate in an instant if companies and governments were forced to choose between Doha and the Quartet, whose combined GDP is almost ten times that of their former ally. Iran, Turkey and Russia might stay on side. But Qatar would lose the US and Europe, where most of its soft power has been developed. Qatar’s success has been dependent on its ability to play both sides. If it loses that privilege, as it would in the event of an interminable cold war in the Gulf, then the curtains could come down.

Which is why, if they wanted to badly enough, Le Drian and Tillerson could end this conflict tomorrow. Qatar’s foreign policy has been concerning for the past decade. It has backed virtually every losing side in the Arab world, and caused a significant amount of destruction in the process. In Syria, Libya, Egypt and Yemen, Qatar has turned a blind eye to the funding of Islamic revolutionaries with the financial muscle to topple incumbent regimes. Its motives are clear; influence over the emergent republics, as it had in Egypt for a year under Mohamed Morsi. But as we review the success of this policy from the perspective of 2017, it seems clear that all that has been achieved is a combination of civil unrest and civil war. The experiment has failed.

Moreover, the Coalition is not going to lift sanctions until Doha suspends its support for the Muslim Brotherhood. When Western leaders survey the Gulf and consider who they should support, they observe two things: firstly, that the foreign policy of the Quartet is much more aligned with their own (it doesn’t seem likely to me that any European or American company would prefer to see a revolution in Dubai instead of a continuation of the present arrangement), and secondly, that Qatar would fold immediately if they applied any significant pressure. The Al Thani ruling family has bet its fortune and power on trans-Atlantic support; it is simply not credible that they would turn to the West’s enemies in the event that an ultimatum was issued. Doha might even welcome an excuse to pause its costly and ineffective programmes. Even if that involves some short term embarrassment. It is hardly going to lose support at home, with the highest GDP per capita in the world.

It would be necessary to make sure that the Coalition understands that it will have to pay a price for decisive Western intervention. The world will be a more dangerous place if our allies get the impression they can freely bully any smaller rival, knowing that the West will always come down on their side. That is however no great hurdle to action; it might even be a positive thing if we can at the same time negotiate greater contributions to counter-terrorism or refugee funding.

Unfortunately the reason why none of this is likely to happen is partly that the West has lost a lot of confidence in its ability to resolve issues in the Middle East since 2003, and partly because it fears for its interests in Doha and the handsome Qatari contributions in Western capitals. This cautious assessment is wrong and will be more harmful to Qatar and the aforementioned interests. The Quartet has no incentive to relent, it can’t afford to and will profit from commercial uncertainty in Doha the longer this drags on. If the West really wants this to end now, it must tell Qatar to reform its foreign policy or face sanctions from a more threatening ally.

Geoffrey Hoon was the UK defence secretary from 1999 to 2005.