Category Archives: Nurses

Another call for a cross party fudge? We continue to break up the large mutual safety net which used to ensure choice, equity, and benefitted all.

BBC News reports on another slicing up of the English Health service. Already Manchester may be reported differently, and now London, when the WHO (World Health Organisation) compares different countries and systems and methods of delivery. The ultimate break up in health is to reduce it to each individuals own resources and their own budget. The absurdity of the current trend may be driven by politicians wishing to avoid blame for failure. So, lets break up the “mutual” a little more….. and lose the advantages of choice and size. Wales had shown what a disadvantage it is to be really small. Yet no lessons are being learnt. Even palliative care is private and charity funded, and in Wales this means “cut”. We used to have a National Health Service, but no longer. No party has shown the courage to rebuild and reinstate it, hence the call for a cross-party group? Small is not beautiful in high tech health care… In addition, no amount of money or manipulation can negate the need for rationing (cutting) overtly, as for vasectomy.

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BBC News 16th November 2017 reports: Sadiq Khan: ‘New deal will help London be world’s healthiest city’

Sadiq Khan says a new deal to improve healthcare in the capital will help London become “the world’s healthiest city”.

London’s health and care services will be devolved to the Mayor of London and London’s councils.

The NHS is being encouraged to sell buildings and surplus land in London which could be used to develop more housing.

Money would be reinvested to build new hospitals and GP surgeries.

The Mayor of London said it would encourage the healthcare organisations to work better together – around issues including payments and workforce.

Mr Khan said: “[The deal is] a really important step in the right direction in our journey to becoming the world’s healthiest city.

“It is vital London has the powers to plan and coordinate health services.”

‘Poor condition’

According to City Hall, the NHS is one of the largest owners of land in London – with an estimated value of more than £11bn……

Terrifyingly, according to the World Health Organisation definition the UK no longer has a NHS

Amazing how England has been able to kid themselves there is an NHS – until now. Manchester’s health devolution: taking the national out of the NHS?

Devolution of health to Wales was a mistake?

Dennis Campbell in the Guardian 16th November: A&E units, GP surgeries and walk-in centres to close as cash crisis bites NHS bodies have decided in the last four months alone to shut or downgrade 70 services, says campaign group 38 Degrees

BBC Bristol news reported 9th November: Nine NHS groups consider vasectomy funding cuts

BBC Wales reports 10th November: Jobs threat at Marie Curie cancer charity centre, Pontypool NHSreality believes that care in the community, hospice at home, etc is the only sensible way to proceed in poorer areas of the country whilst death and dying are not covered.

Cradle to grave? Why the cost of dying is rising.

Hugh Pym for BBC News 18th November 2018: Social care: MPs seek cross-party group to ‘sustain’ NHS

 

 

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The Health Services in “Reality”: even the chief says it’s broken

How on earth did we get here, to this point in denial and lack of long term thinking. Now, if we employ GPs directly from overseas, we will be negating years of training and Improving standards. Teaching Hospitals and Deaneries will be irate. In the longer term the places filled from overseas will be blocked to UK trained doctors. History repeating itself from the pressure in the 1950s? The Health Services are in “Reality”: even the chief says it’s broken. More money will not make more qualified doctors and nurses. The options outlined do not include rationing health care overtly. A knee jerk response tells me it may happen suddenly and unfairly, and without a national debate on the best way to achieve fairness within rationing.

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Chaand Nagpaul, in the BMA Blog in the BMJ opines: A crisis acknowledged and a political choice

Last week, in a speech at the NHS Providers conference, Simon Stevens – chief executive of NHS England – broke ranks from his political masters and laid bare the full extent of the crisis in the health service.

Far from the ‘we’re spending more than ever in the NHS’ rhetoric, or the illusory mantra of politicians promising world-class convenience on second-class funding, Mr Stevens was unequivocal that the NHS was broken, declaring that the current budget ‘…is well short of what is currently needed to look after our patients and their families at their time of greatest need.’

He was openly critical of the impact of austerity on the NHS, describing it as ‘the exceptional choking back of funding growth of the past seven years.’

He mirrored the BMA’s own analysis of the NHS being woefully underfunded compared to European counterparts, arguing: ‘If instead you think modern Britain should look more like Germany, France or Sweden then we are underfunding our health services by £20bn to £30bn a year.’

Indeed I felt a sense of ‘at last’ in hearing language that could have been lifted from the BMA’s own NHS at breaking point campaign.

And as Mr Stevens made patently clear, we are not arguing simply about a number here but about the impact on the health of millions of lives, including explicit government priorities, saying that ’on the current funding outlook it is going to be increasingly hard to expand mental health services or improve cancer care’.

He went further to state it was a ‘duty of candour’ – relating to speaking up when patients were at risk – to ‘explain the consequences’ of this starvation of funds to the NHS.

He also spoke of the impact of inadequate resources on workforce: ‘On the current budget, far from growing the number of nurses and other frontline staff, in many parts of the country next year hospitals, community health services and GPs are more likely to be retrenching and retreating.’

And instead of the usual DH pronouncement of a wishful 5,000 more GPs he was candid: ‘GP numbers over the last seven years have actually fallen but their workload has risen’ – exactly what the BMA GPs committee have been warning of repeatedly.

Mr Stevens also argued for the ‘clinical and the financial logic for integrated care rather than fragmented competition’ – in doing so he reflected 25 years of BMA lobbying opposing the market-driven purchaser provider split.

I hope that he will now go one step further and unequivocally call for an end to competition law enshrined in the Health and Social Care Act – only that will put an end to fragmented care and the billions wasted in the transaction costs of competition.

It is these procurement rules that allow private companies to provide cherry-picked services in the NHS, and also mean that the future proposed accountable care organisations could be sold off to multinationals.

Mr Stevens speech crucially reinforced what the BMA has always argued – that with the UK being a leading health economy globally, the level of funding of the NHS is a political choice by Government. He said: ‘No-one disputes that these are choices that a chancellor could make.’

More specifically he claimed that next year’s funding gap is likely to be £4 billion, citing the analysis of three leading think tanks (the King’s Fund, NHS Providers and Health Foundation).

He asserted this should not be a challenge for the politicians, since it would only bring the NHS back to historic norms. ‘[The independent analysts] show there’s nothing out of the ordinary about needing such a sum. In their words, it would just be a return to the average increases of the first 63 years of the NHS’ history.’

Mr Stevens also rightly reminded government of the promise to the nation of an extra £350m per week paid into the NHS to leave the EU – at a time when indications show the antithesis that Brexit is likely to act as a further drain on NHS resources.

He called on the Government to meet this funding pledge on the fundamental matter of not undermining public trust: ‘You voted Brexit, partly for a better funded health service. But precisely because of Brexit, you now can’t have one.’

It is probably no accident that Mr Stevens’ comments came ahead of next week’s budget; so it’s over to the chancellor, health secretary Jeremy Hunt and the prime minister. The case for investment is overwhelming, as is the daily experience of an NHS that is failing patients, doctors and other NHS staff.

The Government has a choice, of whether to acknowledge the evidence it faces and whether to heed the clear message from the boss it appointed to run the NHS. And a choice between punishing patients or belatedly properly funding the health service this country needs, deserves and which the government itself has promised.

Chaand Nagpaul is BMA council chair

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Disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

We are facing disgraceful post-code differentials in the care of children. We are losing our humanity because we fail to address the rationing issue..

Emma Forde for the BBC News 12th November 2017: ‘I’m dealing with life-threatening situations – but I’m not a clinician, I’m a mum’

Hayley Smallman’s 15-year-old daughter Holly has a series of complex, life-limiting health conditions.

Her cerebral palsy, chronic lung disease and epilepsy mean she needs 24-hour care at their home in Liverpool.

It is estimated there are 40,000 children like Holly living with life-limiting and life-threatening conditions in England alone.

Many of them need palliative care round-the-clock, which is largely provided at home by their families but with the support of community children’s nurses and community paediatricians.

‘Alone and scared’

Hayley says: “I have a community matron and a community physio. They work Monday to Friday, 9am till 5pm. They are great.”

But when it comes to out-of-hours and weekends, Hayley says she is left without any support…..

On the same day: ‘Postcode lottery’ for dying children’s care, report finds

Families of dying children lack support because of a “postcode lottery” in palliative care services, according to a report.

The Institute for Policy Research says 49,000 children have life-limiting or life-threatening conditions in the UK.

The report says Scotland is “leading the way” in ensuring the right care is available to all, but the rest of the UK must follow suit.

The government says it is committed to tackling end of life care variations.

The IPR, based at the University of Bath, blamed a “piecemeal” approach to polices around palliative care and helping the bereaved for a wide difference in services across the UK – notably for children.

According to children’s charity Together for Short Lives – which contributed to the report – seriously ill children are “being forgotten or ignored” by nearly one in ten clinical commissioning groups (CCGs) in England as important services are not being made available.

Only 73% of CCGs provide palliative children’s nursing out of hours and at weekends, meaning children have to go into hospital rather than be treated in the community, the report found…..

…James Cooper, public affairs and policy manager at the charity, said: “The way in which children’s palliative care in the UK is planned and funded represents a postcode lottery.

“The current policy and funding environment has failed to adequately acknowledge the needs of these children, their families, or those that work to support them.”

He said families of children with life-limiting conditions have to co-ordinate a “vast array of professionals and agencies” for the care their children rely on.

“While a number of positive policy initiatives are being developed by the UK’s governments and other agencies, more work is needed to make sure that they bring about more joined-up plans, assessments and services with children and families at their centre,” he added.

The IPR report praised work in Scotland where the government is investing £30m following a pledge to provide palliative care for all who need it by 2021, “regardless of age, gender, diagnosis, social group or location.”

But it criticised the rest of the UK for being “ill-prepared” for the ageing population, and left with “disjointed policies” for people of all ages.

The report’s lead author, Dr Kate Woodthorpe, said: “For too long we have been complacent about death’s social and economic consequences, and our policy responses.

Government can no longer ignore the many, many challenges outlined in this brief.”

Other issues highlighted in the report

  • Only one in six employers have policies in place for employees providing palliative care for someone with a terminal illness
  • Growing funeral poverty – 45,000 people annually seek help from the state to meet the cost
  • A lack of burial space and concerns regarding crematoria capacity
  • One of the lowest rates of organ donation in Europe, while more than one in ten people die in the UK before they get the transplant they need
  • Nearly two-thirds of the UK population do not have a will

The report said the example of the devolution of powers and resources to Scotland offered a framework to tailor services to local populations and allow best practices to be shared.

“National and regional devolution is showing early indications that innovation and modernisation is possible, and Scotland is arguably leading the way with ambitious targets and re-organisation of key policy areas,” added Dr Woodthorpe.

“It is up to the rest of the country as to whether they wait to see how well Scotland fairs, or whether they use this as an opportunity to review, consolidate and improve how they support dying, death and bereavement.”

Scotland’s Health Secretary Shona Robison, said it was “extremely heartening” to be recognised by the report, adding: “It is a tribute to the compassion, commitment and dedication of those working across our health and social care services.

“To achieve our aim it is essential we create the right conditions nationally to support local communities in their planning and delivery of those services and support – to help ensure that the unique characteristics of each individual and family are met.”

The Department of Health said it had made a commitment to address variations within end of life care, including investing £11 million from NHS England into funding for the Children’s Hospice Grant.

A spokeswoman said: “We want all children and their families to receive high quality, compassionate and tailored care at the end of their life, regardless of where they live. That’s why we have committed to improving care in all settings.”

Update 12th November – And I forgot to mention child and adolescent mental health. A letter from an exasperated mother in the Sunday Times reads:

Psychiatry crisis takes toll on young anorexics

The woeful provision for young people with eating disorders led to my daughter being transferred in March to Edinburgh — even though we live in Hampshire (“Crisis in child psychiatry as vacancies soar”, News, last week).

It is totally unsustainable and she cannot build a life outside while she receives care. In early summer she was ready to move on but beds and/or funding were not available, so she has relapsed and lost hope.

This happens to patients time and again; hence the cyclical nature of anorexia. As a mother, I feel I am fighting on all fronts every day to get the right treatment for my daughter — with her condition and her daily or future care — while also dealing with grief and sadness for all that has been lost for our daughter and family, and the fears over what lies ahead for her.

There is a desperate need for more inpatient beds and a variety of treatment settings community, acute or inpatient and step-down) in which there is a greater range of therapy options to enable all the complexities of the illness to be addressed. One size does not fit all.

Incentives to train more psychiatrists, mental health nurses and support workers, plus a specialist eating disorders pathway for therapists, are essential.
Jemma Perkins, Andover

It’s about to blow up. There is no Mr Fawkes to arrest, blame and punish (hang draw and quarter) for the coming NHS failures

If you are planning a holiday rather than saving that heard earned cash, you might want to consider the true cost of health care, what will not be available to you in your particular Post Code, and what you could afford to buy straight, or insure for. Being off work for long periods, especially for mental health problems is soul destroying, and reduces standards of living. Houses have to be re-possessed, and re-employment is difficult. Only the large state employers seem to ignore the mental health record. Small organisations are unlikely to keep those who keep needing time off unpredictably. If you do go on holiday, especially to Greece, take cash! The bomb under the health service is about to go up, and there is no Mr Fawkes to arrest, blame and punish (hang draw and quarter) for it’s failures. If, like most people you cannot contemplate a life without mutual health cover, find out what your premium would be and take it off your income… scary. “The sums involved are colossal” – see below, and tinkering with fraud and overseas patients are distractions.

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Tony Stubbington reports in The Sunday Times 6th November : NHS cash crisis reveals the fractures in our finances. The chancellor has little room to prop up the health service in his budget

At Birmingham Children’s Hospital, staff who go the extra mile get the chance to be named “Star of the Month”. Looking through the recent nominations for the award, Sarah-Jane Marsh noticed a worrying trend. The number of people who were nominated for working through weekends or holidays without extra pay was “unbelievable”, said the chief executive of Birmingham Women’s and Children’s NHS Foundation Trust.

“We are running on goodwill,” she said. “People don’t take breaks. They work through annual leave. Over the past two years we’ve been cut to the bone.”

The trust’s funding has not kept pace with steadily rising patient numbers and the soaring cost of ever-more sophisticated treatments, according to Marsh. Staff have stretched themselves, but the cracks are starting to show. In the three months to September, the trust missed its target for A&E waiting times for the first time since 2003, she said.

Her complaints cut to the heart of the dilemma facing Philip Hammond as he prepares for an extremely politically charged budget on November 22. Most government departments claim they are at breaking point and have started leaking stories about the strains on policing, social care, prisons and creaking infrastructure.

Yet there is simply not enough money to throw more than a bit of cash at some minor problems and hope for the best. The chancellor already faces a productivity slowdown expected to blow a hole in plans to balance the budget by the middle of the next decade. A cash injection for the NHS could sink these plans.

 

Image result for cash crisis cartoonThe Sunday Times 5th November reports on child and adolescent mental health with:

Parents beg universities for help after rash of suicides.

Crisis in child psychiatry as vacancies soar.

Coroner attacks failures of care for anorexic teacher.

But these are the thin edge of a very large wedge. No commissioning group fails to accept that child psychiatry is core health service provision, but in a cradle to grave and un-rationed NHS, why is dementia excluded? Why is palliative and terminal care funded by charities? Why is psychiatry (40% of GP work, and rising) not part of the training for all GPs? We know it is unpopular, but it becomes much less o once doctors are exposed to it as a speciality. I wonder how many of our UK psychiatrists trained in a UK medical school? This is a speciality that needs good communication and cultural awareness…. Even in Germany they have trouble with “fakes” which makes me wonder about quality control…

Shortage Occupation List – Royal College of Psychiatrists

1,000 more psychiatrists needed to tackle ‘unacceptable failings’ in care

Shrinking: The Recruitment Crisis in Psychiatry | The Psychiatry SHO*

Why Don’t Medical Students Choose Psychiatry? | The Strangest Loop

Psychiatric nursing: an unpopular choice. – NCBI

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Worried there may be an epidemic – of deaths, many alone at home… A precarious health service..

Niall Dickson opines in the Times 9th October 2017: This will be one of the NHS’s toughest winters and flu is not the only epidemic professionals fear. Mental health (Elderly, middle aged and teenagers), Diabetes from Obesity, staff bullying, staff attacks, drug addiction  and almost any other service you like to name.. The future of the whole NHS is precarious..

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It is becoming hard to overstate the perilous state of the health and care system in England. We have just polled our members — 92 per cent of healthcare leaders are “concerned” about their ability to cope this winter and 62 per cent of those are “extremely concerned”.
Last year the NHS managed well in difficult circumstances. Yet the impact on patients was evident. In early winter, waiting times in the big emergency departments rose sharply, with nearly one in five patients waiting longer than the four hours that is supposed to be the maximum. And there were ten hospitals in which less than 70 per cent of patients were seen within four hours.
This year there is an even greater sense of foreboding. There is much activity in central NHS bodies and an understanding of the political sensitivity of this issue — in part this is because of the obvious damage and distress that such delays cause patients and their families, but it is also because emergency departments are seen as a litmus test for the rest of the system. If the health service cannot cope at its front door, what lies behind it will also be struggling.
The causes are well known — we have a rising population. We have not invested enough in the services in the community that take pressure off hospitals, and we have a problem recruiting skilled staff. Emergency admissions are continuing to rise — in the first quarter of this year there was a 25.9 per cent jump in responses to life-threatening ambulance calls — so the ambulance service too is under increasing strain.

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The current levels of concern are heightened by fears that we may not escape a flu epidemic this year. Simon Stevens, CEO of NHS England, has pointed out that hospitals in Australia and New Zealand have been hit by the worst flu season in years; there is a good chance the same H3 strain is heading our way. A lot of work is underway not just to improve the flow of patients through hospitals but to relieve pressures elsewhere in the system. At the heart of all this will be effective planning and good co-operation across the entire health and social care system, but there is only so much that can be done.

A cash injection at this stage is unlikely to solve the winter pressures, but the chancellor must revisit the pencilled-in figures for 2018-19 and 2019-20, which if left as they are would guarantee more crises ahead and further delays to the reforms that are needed. For the longer term, the budget in November will be an opportunity for the government to underline its support for the NHS and to make sure it is deternot preside over a deteriorating service.

Niall Dickson CBE is chief executive of the NHS Confederation, a membership body for NHS health and social care organisations

Kat Lay reports: NHS straining at the seams as our bad habits add to pressure and Cash boost can’t save NHS from another winter crisis and Mental health staff attacked ‘on daily basis’

Chris Smyth: NHS is given six weeks to empty beds in flu alert

and Financially the lunatics running the asylum have run out of ideas in reigning in the cost of locums. Experience is very valuable in medicine and the most experienced radiologists, anaesthetists ans surgeons command high prices in their market, one created by politicians.

A perverse incentive epidemic, especially in mental health – both for GP’s pay/workload in UK and increased organ donors in the US, or dying, means that the systems are likely to get worse ..

An epidemic of nationwide bullying. In most dictatorships this precedes dissolution or breakdown….

Rosemary Bennett 10th October : Half of expelled pupils are mentally ill

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BBC News reports “peanuts” spending: Scottish government announces mental health funding boost

Nick Triggle for BBC News: NHS future precarious, says regulator

Hearing loss and dementia: more research is needed. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us …

More research is needed into the relationship between hearing loss and dementia. Patients with hearing aids in hospital need special consideration, and for over 70s, that’s over 60% of us … The rationing of hearing aids is patently perverse, and the outcome could be more long term dementia care demand on the state. And of course the politicians making the decisions today will not be those addressing the future problem.

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A letter from Dr Ted Leverton in the JRCGP October 2017 reads: 

Iliffe and Manthorpe’s editorial in the August issue1 is apposite in view of the publication in July of the Lancet Commissions’ report Dementia prevention, intervention, and care, which expands on several of the themes raised.2 In particular, the editorial’s focus on the role of general practice in prevention and research is to be welcomed. However they do not mention hearing loss, to which the Lancet report devotes considerable space and ascribes a significant potential preventive role. Hearing loss is independently associated with developing dementia in about one-third of cases.

Recent research has suggested that use of hearing aids may reduce or prevent the increased prevalence of dementia seen in adults with hearing loss.3,4 This needs confirmation, as current evidence is weak due to the large number of confounding factors. General practice is ideally suited to carry out this research thanks to our large-scale and long-duration databases. In the meanwhile, GPs are likely to see increasing numbers of patients asking for referral for hearing aids, as some in the commercial sector are stating this benefit of hearing aids as fact. Such referral should be expedited; GPs are sometimes accused of minimising hearing loss and delaying referral, but early users of hearing aids are more likely to use aids successfully over a longer timescale as they can be difficult to use. Hearing loss is associated with depression and social isolation;5 denial of the disability is common, as is irritability and interference with relationships. By the age of 70 years, 70% of GP patients have hearing loss. If in doubt, or if the patient is reluctant, a simple validated screening test is available over the phone or online.6

REFERENCES

  1. (2013) Hearing loss and cognitive decline in older adults. JAMA Intern Med 173(4):293299. Lin FR, Yaffe K, Xia J,et al.
  2. (2015) Hearing loss and cognition: the role of hearing aids, social isolation and depression. PLoS One 10(3):e0119616, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356542/ (accessed 5 Sep 2017). Dawes P, Emsley R, Cruickshanks KJ, et al.
  3. Action on Hearing Loss. Check your hearing. https://www.actiononhearingloss.org.uk/your-hearing/look-after-your-hearing/check-your-hearing/take-the-check.aspx (accessed 5 Sep 2017).

A “moral vacuum” at the heart: Nurses ‘have no time to show compassion’ and need a leader with a moral compass.

Chris Smyth in the Times reports 26th September: Nurses ‘have no time to show compassion’

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A “moral vacuum at the heart of nursing” has left NHS staff following tick-box rules rather than trying to do the right thing for patients, a study of professional values has concluded.
Nurses are so ground down that they end up as “robots going through the motions”, researchers warned, with a focus on clinical skills driving compassion from the job.
Eight in ten nurses say their work conflicts with their personal values much of the time. The moral disengagement that results puts patients at risk of another Mid Staffordshire-style scandal, the study concluded.
Kristjan Kristjansson, an educational psychologist at the University of Birmingham, said the state of nursing was far more depressing than that of any other profession he had studied, including lawyers, teachers and doctors.
“When you’ve been working for five years or more, usually you realise that following the rules is not the only important thing, you have to rely on your own moral compass.

But the nurses didn’t,” he said. “We have identified a moral vacuum at the heart of nursing in the UK.”
His study of 700 nurses found 45 per cent saying they acted the way they did because it was what the rules decreed, rather than because it was the right thing to do.
“Their only standard was what was written down in the codes,” Professor Kristjansson said.
“They are the only professionals where reliance on their own character compass does not pick up as they gain more experience. This fact probably says a lot about the current state of nursing.”
He argued that this directly affected patient care, saying: “If you’re a patient, you can tell if a nurse is just going through the motions.”
The problem was nurses feeling they did not have time to care for patients properly, putting them in greater conflict with their own ideals than other professionals, he said.
“Nurses say they don’t have time to show care and compassion,” he said. “Often there have been times when they come away from patients feeling they did not do as much for those patients as their hearts dictated and that the patients did not receive the care they deserved.”
Professor Kristjansson said that retreating to a “Mr Spock mentality” where they just followed the rules means they would struggle in a morally stressful situation such as that at Mid Staffs, where few nurses spoke out against neglect of hundreds of patients.
“There won’t be any whistleblowers, people will just turn into automatons, robots at work,” he said. “The only thing that seems to wake politicians up is a new crisis, which is very sad.”
While saying that it was positive that nurses were now seen as professionals requiring degree-level skills, rather than simply being doctors’ assistants, Professor Kristjansson said this had come at a cost.
“The pendulum has swung too far in the other direction, away from the ethical core of nursing,” he said. “The whole professional duty since the days of Florence Nightingale has been not only the administration of medicines correctly but creating an ethos in the hospital that puts patients at ease.”
Sir Robert Francis, QC, who chaired a public inquiry into the Mid Staffs scandal, backed Professor Kristjansson’s call for more emphasis on virtue and character in nurses’ training.
“A commonly accepted set of values has to be the foundation of professional practice to enable those with this vocation to navigate the ethical dilemmas they face daily,” he said.
Janet Davies, chief executive of the Royal College of Nursing, said the report “demonstrates the emotional pressure on caring professions who, when faced with an inability to work as they know they should, become compromised”.

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NHS pay scales 2017-18 | Royal College of Nursing

Check average Nurse salary | Nurse salary information on totaljobs.com.

Nicola Merrifield in the Nursing Times: Plans to end public sector pay cap ‘must make up for lost nurse earnings’, say unions

Paul Francis in The Medway Times 25th September: Nurses from Philippines going for jobs at Medway Maritime Hospital fail English test