Thursday, January 22, 2015

Before you sign the CDF petition...

I love a good petition, me; equal marriage, women's rights, end of life care, I'm all over issues like that and usually first in line to add my name to the cyber-voice but as I get numerous requests from Facebook friend and Twitter chums to sign a petition protesting against cuts to the UK Cancer Drugs Fund (CDF) I'm afraid that I must decline. I do not intend to get into a justification regarding my non-participation, instead I would ask that you, dear reader, just consider the following points before you decide to sign the petition or not.

  1. The CDF was created to meet a political agenda not a clinical need. The lobbying power of big pharma companies and the ideological stance of the coalition government translated into what Professor Peter Clark (an oncologist who runs the CDF) refers to as a way of exploits the special willingness to pay for cancer drugs (
  2. In the UK NICE take responsibility for assessing both the clinical and cost effectiveness of medications and treatments. Despite the image portrayed by certain sections of the media, a NICE meeting does not consist of a group of uncaring people seated around a table dismissing treatments by simply saying saying' this is too expensive'. On the contrary, NICE committees are made up of experienceclinicians, academics and lay people and they scrutinise all submissions very carefully. Often, the weaker the submission the  harder the committee tries to find evidence to support funding the treatment. Believe or not, the people of a NICE committee do not have 'No' as their default setting.  However, the cancer drugs fund will consider funding any treatment that is too new or too expensive to obtain NICE approval. What has this done to the pricing regime of the pharmaceutical industry? What has this done to NICE?
  3. There is clearly an underlying attitude that providing extra time for people who are dying is a societally acceptable, and this cannot easily be contested as a bad thing. However this begs the question; why only people dying of cancer? Why are people dying of AIDs or MS or any other number of terminal illness not equally worthy of preservation? It would be cynical in the extreme, perhaps, to point out that generally cancer is a disease of old age and older people are the ones likely to vote.
  4. There is no bottomless pot of money here, if we continue to support he CDF, what services do we reduce or close? IVF clinics? Dementia centres? Drug and alcohol services? The  money must come from somewhere. Helen Crump, in her recent blog on this subject his highlighted that we have no information about which services have already suffered through the development of the CDF and this is an important issue in these increasing squeezed times
  5. There are increasing concerns regarding the relationship between charities and big pharma. Some are open about this relationship see here, for example but others may be less transparent, this has been discussed by  GP Margaret McCartney and further highlighted by blogger Dick Puddlecote here. Once this relationship is considered it make the lobbying of charities a little harder to countenance.
Cancer is a terrible disease and one that most of us fear, if we are honest, and initially this makes protecting the Cancer Drugs Fund a no-brainer when we are asked to sign the petition because who would want to deny treatment to dying cancer patient.  What I hope this blog post will do is make people think about the consequences of continuing to support this black hole of funding which overspent by 30.5 million pounds in the last financial year, or at least google it to get both sides of the argument before they make up their mind whether to sign or not. 

Tuesday, May 28, 2013

Challenging the Nightingale Myth

In 2009, the one hundred and fiftieth anniversary of the publication of the seminal work ‘Notes on Nursing’ passed more or less un-remarked across the planet. This lack of interest, particularly when compared with the global interest that has been focused upon ‘Origin of Species’ (which shared a similar anniversary), raises the question – is Florence Nightingale’s still relevant to nursing?

Historically, Nightingale’s theories formed the foundation of nurse education systems in countries from China and Japan to America and Australia. A brief examination of the literature suggests that, although the debt owed to Nightingale is often acknowledged by nurse educationalists, there is little evidence to show if (or how) these theories are ever deliberately reviewed or consciously incorporated into contemporary nursing curricula. What is clear is that Nightingale holds an unassailable role as the creator of modern nursing, and this role is rarely if ever questioned.

Nightingale’s life reconsidered

Without doubt it is clear that Nightingale was born into a wealthy and highly privileged environment, spending her early years touring Europe with her parents and her older sister.  Just how wealthy and comfortable Nightingale’s life was up is best illustrated by the small fact that she dressed herself and fashioned her own hair for the first time in 1853, when she was in her early thirties.

Nightingale was extended a degree of autonomy that was unusual in Victorian gentlewoman in that her parents appeared to hold a relaxed attitude towards matrimony for their youngest daughter. Women of the upper middle classes depended heavily on marrying "up" into the upper classes, therefore gaining social prestige as well as a great deal more worldly goods (Rowbotham, 1989). However Nightingale refused to marry, keeping one suitor Richard Moncton Mills waiting seven years for an answer to his marriage proposal, finally rejecting him on the grounds that she could not have “work” of her own if she chose to follow her heart into a society marriage. Marriage would destroy her chance of serving God’s call.

Thus Nightingale is perceived as a force for good and change agent from whom all modern nursing flows. However excavation of an almost archaeological nature can present a slightly different picture of “The lady of the Lamp”. The image of a solitary woman making her way through the wards of Scutari watching over the sick and injured also underlines the fact that Nightingale did not work well with other people, for example

  • She rejected Mary Seacole’s offer of help when the Cholera epidemic was at it’s worst even though Seacole was an acknowledge expert in the disease (Simkin 2003)
  • She displayed considerable resentment towards people, Crimean doctors in particular, who had dared to rise above their station (Williams 2007)
  • She  was noted for her exaggerated statements and vituperative asides in relation to the senior medical staff, even going to far as to assert that  John Hall (Principal Medical Officer in the Crimea) had no adequate medical qualification, when in fact he was an FRCS, by examination, and had an MD from St Andrews  (Williams 2007)

It is unlikely that Nightingale would have achieved what she did in the Crimea and afterwards without having a strong personality. Nonetheless she wasn’t averse to using the achievements of others to further her own ambition:

  • Nightingale publically stated that she regarded the establishment of a medical statistical branch as one of her most important proposals adopted by the Royal Commission in 1857. When, in fact been Andrew Smith (director general of the army medical department) proposed in 1855 that a board for medical statistics be established formally within his office, a function that it was already performing
  • She took credit for the idea of the need for an army medical school although the idea had been proposed some 50 years previously
  • St Thomas’s was selected by Nightingale to host the first nurse training school as this allowed her to  to capitalise upon the  work of Mrs Wardroper, the Matron, who had already initiated a programme of reform in 1855
(Williams, 2008)

Even Nightingale’s own sister, Parthenope with whom Florence had a stormy relationship at best noted that Florence was 'a shocking nurse’, arguing that;

“She has little or none of what is called charity or philanthropy, she is ambitious - very, and would like... to regenerate the world... I wish she could be brought to see that it is the intellectual part that interests her, not the manual.'
(Cited by Bostridge, 2005)

Nightingales actions on arrival in Scutari would also suggest that she had no real “feel” for nursing; one of her first actions being to dismiss the nurses that were already working in the military hospital. This caused two main problems, firstly it removed a number of effective nurses from the caring arena and secondly it left 38 nurses, the women Nightingale had taken to Crimea with her, the unenviable task of caring for over 3,000 patients.  Within a few months of Nightingale’s arrival, patient numbers had risen to 5,000 but no extra nurses were requested (Williams, 2008). Indeed, when Mary Stanley, a long standing friend and admirer, met with Nightingale in December 1855 to offer the services of 21 Catholic nurses whom, inspired by Nightingale she had bought to Turkey to nurse the injured and sick, the offer was curtly rejected (Baylen 1974).

It is not inappropriate to suggest that the opportunities afforded to Nightingale by the public engagement with the Crimean war, it was after all the first war to be fully reported in the national press, allowed her to promote herself and her activities in a remarkable manner. The emotive and evocative picture of “The Lady with the Lamp” only came about because Nightingale herself had banned all women from the wards at night (Cohen, 1984) on the grounds of alleged immorality, although no one seems to have questioned how an immoral environment could flourish with patients as sick and badly wounded at those at Scutari.  John Hall, the Principal Medical Officer in the Crimea, denounced her as a publicity seeking meddler (Williams 2008).

 Regardless of the subdued rumble of criticism, Nightingale managed the Victorian media with a skill that would be recognisable to a number of ‘celebrities’ today. Such was the level of public adoration for this woman – evidenced by paintings, poetry and even a fan club - that experienced and skilled nurses who took issue with her approach to care felt unable to express their approbation in the public domain. Baylen (1974) cites a letter from Mary Stanley, written in 1855 in which she notes;

I came out loving Florence [Nightingale] … I was long and loth (sic) to believe she was not as great as I believed her to be.  If you knew what it was to me to hear every one complaining of her and to feel that the blessing given by the nurses is so immense, and that so few comparatively enjoy it.”
(Baylen, 1974 p 189

Nightingale’s strangle hold on the organisation and delivery of care upset a number of experienced nurses who felt their only option was to return to England.  In the same letter cited above Stanley goes on to complain;

“Miss Emily Anderson has been for a fortnight at the General Hospital, but she has sent in her resignation for she felt she could not work with Florence.

And further notes that,

Miss Tebbutt has I believe written to you. She, I think, will wish to go home, she is so miserable. … the work they are allowed to do is so very small compared with what might be done, or what they could do at home. The Irish nurses feel this especially.”
(Baylen, 1974 p 189)

It is clear that Nightingale did not appear to have the skill of friend making, although she never hesitated to exploit the influence of acquaintances to further her own ends.  Rajabally (1994) suggests that Nightingale’s judgmental attitude made her an unsympathetic character even though her public manner was gentle and unassuming.  Elizabeth Gaskell, a contemporary of Nightingale’s wrote that under her charming exterior there existed a hardness and singleness of purpose which had developed through years of frustration. Nightingale’s  remaining letters illustrate  her crushing sarcasm and how she plotted and planned and subdued people to her will (Bishop, 1960) Rajabally (1994) goes fso far as to suggest that her  controlling and manipulative behaviour  whilst at Scutari and her reclusive behaviour following her return from the Crimea was symptomatic of narcissism and self-hatred. 

Nightingale on the World Wide Web.

Nightingale maintains her presence on the World Wide Web – A search on Google Scholar using the Search term “Florence Nightingale” shows 33,700 hits, using the search term “Florence Nightingale and Nurse Education” provides some 21,500 hits and the search terms “Florence Nightingale in the 21st Century” gives 2, 860 hits. That implies that in excess of 33,000scholarly papers focused upon or quoted from Florence Nightingale’s works.  These works are not confined to nursing journals but cover medical, historical and philosophical journals also.

By searching on the main Google web site, arguably the search portal that many non-academics would use in preference to Google Scholar, the search term “Florence Nightingale” brings up 1,150,000 web sites which include Wikipedia ( ), the Florence Nightingale Museum ( ) and pages that are designed to appeal to school children who, clearly are still being asked to investigate Nightingale as part of their studies ( Almost without exception, these pages perpetuate the Nightingale image as the saintly and heroic “ Lady of the Lamp” and reiterate the same historical facts, many of which show Nightingale in a highly positive light. Even the entries on Google Scholar which, one would anticipate would show a higher degree of critical appraisal, tend, in the main, to be laudatory.

Nightingale's Legacy
It is ironic that whilst Nightingale is widely held to be the originator of the educated and professional nurses that practise today it is the area of education that her ideas are most irrelevant. Whilst the clinical concerns that she wrote of remain focuses of concern today her ideas about education; no exams, no registration, the role of the nurse as a subordinate care provider, are not. Whilst her legend is promulgated via the World Wide Web she will be perceived as a selfless crusader and the less positive aspects of the birth of the modern nursing will be sidelined. Although teaching nursing history has, in many cases been sacrificed in order to focus upon practical, care driven subjects, there is still a place for educators to encourage nursing students to explore Nightingale’s actions and legacy and to examine her motivations and decisions from a more balanced and critical perspective than is currently the fashion. I'm not saying we should denigrate her undoubtedly spectacular achievements, but I am saying that for a profession that prides itself upon using evidence and subjecting ideas to critical appraisal we seem strangely reluctant to subject Miss Nightingales actions and legacy to such scrutiny. Nonetheless, however Nightingale is viewed; saint or sinner, the contribution that she made to nursing cannot be ignored. Making allowances for the style of writing of the time, her obituary in the New York Times, perhaps sums up her current relevance best;

“Perhaps the greatest good that has resulted from her noble life has been the setting in motion of a force which has led thousands of women to devote themselves to systematic care of the sick and wounded”.
New York Times, August 15th 1910


There is a slide share presentation to complement this blog here


Baylen, JO (1974)  The Florence Nightingale-Mary Stanley controversy: some unpublished letters. Med Hist 18(2): 186–193.

Bishop, W. I. (1960). Florence Nightingale’s message for to-day. Nursing Outlook, 8,246-247.

Bostridge, M (2005) Florence Nightingale: the Lady with the Lamp. Available at

Cohen,  IB (1984) Florence Nightingale.  Scientific American 250(3):128-137

New York Times (1910) OBITUARY Miss Nightingale Dies, Aged Ninety. Available at 

Rajabelly, M (1994) Florence Nightingale’s personality: a psychoanalytical profile  Int. J. Nurs. Stud., Vol. 31, No. 3, pp. 269-278,

Rowbotham, J (1989) Good Girls make Good Wives. Blackwell. Oxford

Simkin, J (2003) Florence Nightingale. Available at

Williams, K (2008) Reappraising Florence Nightingale. BMJ 337:a2889. 1461-1463