Sunday, 29 January 2017

Shimmy, shimmy: Probably not the answer to solving our health and social care problems

Occasionally certain words stick in my mind for a while. PROBABLY was such a word this week. The global brewer Carlsberg of course made the word famous in its long running marketing campaign, first started in 1983 – probably the best beer in the world. Although the company decided to drop the phrase in 2011, it has been reprised off and on since then, sometimes humorously, and at other times, not so. Remember the 2015 ‘beach body ready’ advertisement? it was unacceptable and crass, particularly as their marketing skills have proved so successful in the past. Will they continue to use the phrase in future advertising? - Probably.

Anyway I am digressing. Last week I attended a number of Board meetings during the week, the first of which was at Start in Salford, a creative arts and wellbeing centre, who work with vulnerable people from all walks of life, see here. Much of the discussion was around the uncertainty of achieving financial security in order to continue their work, a similar situation in the Haelo Board meeting I attend later in the week. Interestingly, Haelo also draws on the arts in delivering their improvement science innovations to health and social care organisations (see here).

At both these meetings the discussions included identifying sources of future funding; how to grow; whether they were doing the right things and doing these in the right way. Despite the increasingly complex and turbulent world both organisations work in, they have got access to some great strategists; they have clearly articulated ambitions and aims; and whilst the opportunities maybe challenging, these are built upon achievable objectives. Do I think both organisations will still be here this time year? - Probably.

At this month’s Trust Board meeting, members (including the public) heard a presentation on our mortality statistics. The Summary Hospital-level Mortality Indicator (SHMI) describes the ratio between the number of patients who die following admission to a particular hospital and the number that would be expected to die compared with the average population, and the presenting condition. Hospitals not meeting their SHMI targets can be put into special measures, and the Board replaced. Given this unpalatable outcome, is it is possible to fiddle the figures? – Probably. Would any Trust do that? – Probably.

SHMI, despite its statistical underpinning doesn’t provide a true picture of how the quality of care impacts on death rates, and even if it did, we need to remember that just 3.5% of all deaths are deaths that occur in hospital. Of these deaths, a similar figure (3.6%) might have been prevented. Likewise, SHMI absolutely fails to distinguish between those patients admitted for treatment or admitted for ‘human or comfort care’ due to failures in local social care service provision. Does this mean more older people are coming into hospital to die? – Probably.

The Board at Wrightington, Wigan, and Leigh NHS Trust is blessed by having Martin Farrier, a Consultant Paediatrician, absolutely committed to providing high quality family centred care for children. He also leads on the Trust’s work on reducing mortality across all areas. He is best described as the ‘Brian Cox’ of mortality. He understands statistics, loves data, can communicate the most complex of issues with great humour, authenticity and authority. He enables everyone to better understand what might be involved. Last week he took the Trust Board through what lies behind the current SHMI situation. It was both an interesting and challenging presentation.

Whilst the overall number of patients being admitted to the hospital continues to decline, the number of patients over the age of 75 being admitted continues to grow. There was 11% more patients admitted from care homes in 2016 than in the previous year. There are more people over the age of 65 living in Wigan (59,000) compared to Salford 39,000, which has a more typical city population. Many of these people will be living with dementia and have other comorbidities of complex life shortening conditions. Is this a situation that is likely to get worse? – Probably.   

Recognising the emergent and growing problems posed by these demographic shifts Martin offered us a glimpse into a possible future and the very difficult choices we might need to consider. However, things we could do now that would help deal with current pressures on services included the creation of an acute health village - if people pitch up at the hospital lets just treat them with a full range of services, not just A+E; adopt less heroic approaches to the care and treatment of the elderly and frail - for example, Warfarin as a stroke preventing medication, ceases to be beneficial due to the increased risk of falls and internal haemorrhage in the 75+ age group; instead of ‘Do Not Resuscitate’, consider ‘Do Not Bring Back to Acute Care’ agreements.  Are these changes likely to be resisted by many practitioners? Probably. 

For the future, should we consider the creation of ‘Care Villages’, shared communities where ‘human’ as well as ‘health’ care might be better provided for those living with conditions such as dementia; where we might really gain the benefit of digital health opportunities; and where the current social care pressures that impact upon hospitals could be shaped by a different economic model and funding approach? Probably. Uncomfortable thinking? - Probably. But shouldn't we be doing something about it? Absolutely! 

Sunday, 22 January 2017

Unrelenting Kindness meets Unconditional Positive Regard - Being There for Others

It appears difficult to find data on how many people change their GP each year. The best I could do this morning was a study published in 1997 which shows up to 4% changed their GP for reasons other than moving house, and a more recent study in 2012 which showed a lower figure of 1.9%. If one forgets percentages and thinks about actual figures, this could mean up to 1.3m people in the UK might change their doctor each year. The top 3 reasons given in both studies for moving to a new GP were: (1) accessibility (including distance) (2) attitude of doctor (rudeness, not listening) and (3) clinical management (the difference between what the person wanted and what their GP gave them, most often around the prescribing of medication).

I mention these facts for 2 reasons. One of my daughters recently changed GPs. In the UK it’s easy to do, and you don’t even have to let your GP know you are doing it. She changed her GP practice due to a conflict over getting a flu vaccination for one of her young children. The child’s school had said it should be done by a GP, the GP said they wouldn’t do it as it was available to children at school. Now my daughter is aged 34 and from a generation that appears to know best, knows what they want, and have no problem expressing their expectations in person, on-line, by phone, and often do so with utter conviction they are right. I know as I’m her Dad.

Her sons eventually got their flu vaccination – from a practice nurse at the new GP practice, and all is well. Her story is perhaps symptomatic of what might be contributing to some of the current problems with the UK health care service. Many people have high expectations of what they are entitled to, including the right to the best possible health care right now, right here. Maybe it's simply a form of cognitive dissonance that results in so many people turning up at A+E departments when they are clearly not requiring emergency care. Maybe it’s some mass renaissance evocation of the Talcott Parson sick role theory where notions of personal rights trump any sense of personal responsibility for one’s health and well-being.

As I said in last week’s blog (see here) there is a great deal more we could do, need to do, in using education aimed at helping more people take sensible and informed decisions over managing their own health care – and it is the generation coming through in our schools today that perhaps deserve the most focus. Of course, there will always be people that will need access to effective, evidence based health care, and in the UK we provide this extremely well.

For many years I have been trying to promote a greater understanding of what the practice of health care means in relation to the science of health care. The second reason for my noting the GP data above comes from a fantastic example of what I mean by the practice/science dichotomy. Last week, after I published my blog I received a Twitter DM. It was a message that came from a man I have never met. He told me of how his thinking had changed after reading a blog I had posted way back in 2010, which included a comment on a wonderfully courageous young lady I had met who described her experience of receiving mental health care over an 8 year period.

When I met her she was 19 years old and talked of the care she had received from her GP, which she described as being un-remitting, constant and reliable. Hearing her account made me think more about the notion of unconditional positive regard (UPR) for others, and this is what I was commenting upon. UPR is a concept I have tried to employ over many years in my clinical practice, as a manager, leader and educator. It was this young ladies GP who contacted me and he told me at the time he was reading my blog, he wasn’t familiar with the UPR.

Of all the skills a health care professional has to acquire UPR is by far the most complex and difficult to learn. Being able to accept other's unconditionally helps ensure that the health care professional is able to provide non-judgmental support and care. For me UPR is an essential requirement in truly providing person-centred care. It is not an easy approach. In mental health care, being there for others whatever they say, or do is crucial in establishing and maintaining a therapeutic relationship. I believe UPR helps practitioners to stay there, and be there for others.

The GP who contacted me works for one of the most exciting organisations providing health care in Manchester. Here is a quote from their website – The greatest disease in the West today is not TB or Leprosy; it is being unwanted, unloved and uncared for. We can cure physical disease with medicine, but the only cure for loneliness, despair and hopelessness is love -  They have further developed the notion of UPR in their work and now promote and live the notion of ‘relentless kindness’. Just have a look at their website and be truly inspired! 

When I was trying find data on how often we might choose to change our GP one of the sites I came across was one quoting the Competition and Markets Authority data on banks. They reported that although about 10% of us might change our bank, over 57% of us have been with the same bank for over 10 years, and about 40% of us have had the same bank account for over 20 years. Indeed on average we are more likely to stay with our bank (typically for 17 years) than remain married – the average marriage in the UK lasts 11 years and 6 months. It would appear that in many areas of our lives, love and kindness are attributes not to be ignored, but nourished.

Sunday, 15 January 2017

The NHS: no easy solutions but lets stop the shouting and start talking

Stories of the NHS have been hard to ignore this past week. There was the British Red Cross perhaps ill-judged description of the NHS facing a ‘humanitarian crisis’; the May/Corbyn ‘tit for tat’ funding polemic; alongside stories of blame involving health tourism, older people and angry, tired doctors. Borrowing a term from psychology, it’s clear that there is great deal of ‘high expressed emotion’ in many of the narratives used by people to describe the state of our NHS. In clinical practice, there are 3 dimensions of high expressed emotion: hostility, emotional over-involvement and critical comments. It is possible to see these dimensions played out in some of the recent commentaries on the NHS, and perhaps its easy to see why.

The NHS remains a precious feature of British life. Every 36 hours the NHS sees 1m people. Most people in the UK have grown up knowing only the comprehensive health service we have today. In most instances the care, treatment and support we receive is completely free at the point we access it. For many it is the envy of the world. The US based Commonwealth Fund, founded by the philanthropist, Anna Harkness in 1918, and which carries out independent research on health care issues and how to improve health care services, declared the NHS to be the most impressive health care system in comparison to services in 10 other countries (Australia, Canada, Germany, France, New Zealand, Netherlands, Norway, Sweden, Switzerland and the US). In 2014, the system was number 1 in terms of efficiency, effective care, safe care, co-ordinated care, patient centred care and cost related problem.

Such a high quality service doesn’t come cheap. It costs some £120bn a year to provide health care to the 66 million people living in the UK. This is a population that is set to increase to 69m by 2024 and to 73m by 2035, but is also expected to continue aging. The average age across the population in 2104 was 40, by 2039 it will be nearly 43. The number of people aged 60 and over has already reached 15m and of those, 1.8m are aged over 85. It’s worth noting that some commentators have claimed we don’t spend as much on health care as a percentage of our GDP as other countries, which is true in comparison with the US, but less so with some European countries for example.

However, I’m not sure that simply providing more money would solve some of our current pressures. Of course it would help, but as economist’s at the Health Foundation noted in 2015 (see their report here) the means of raising additional funding (through increased taxation) is unlikely to be a long term sustainable solution. I think that in addition to thinking about how more money can be provided, as a society we need to also consider what we could do (perhaps need to do) around health care expectations and health education.

Over the last 20 years I have been privileged to travel to many parts of the world as part of my job as an academic. Often I have been able to fit in a visit to the local health services. I have seen vulnerable children locked up alongside dangerous patients in forensic mental health units in Kenya; health care provided in crumbling buildings in Hungary, Slovakia, Lithuania, and the Czech Republic; special care baby units in Uganda where the incubators were stacked 2 high; remote care in Finland and Australia; and emergency care in Brazil that brought to mind what I imagined 14th century Bedlam to be like.   

What I’ve noticed in all these examples, so often far removed from what we in the UK have grown to understand to be modern health care services, has been the desire to support and care for those in need of care and help. For me this was exemplified in one visit in particular. It was a visit to the Sindh Institute of Urology and Transplantation (SIUT), a hospital in Karachi, Pakistan. Leaving aside the fact that I was accompanied everywhere by a security man complete with a Kalashnikov rifle, it was a humbling and informative experience.

Patients were offered a comprehensive service, from first assessment, diagnosis, and treatment and where appropriate aftercare – it was a one stop shop service and all provided for free. All the care was provided by healthcare professionals who were enthusiastic, talented and extremely hard working, many for nothing other than the opportunity to work at the hospital. The conditions in parts of the service were awful. There were often patients queuing for many hours to be seen, and many more being cared for in corridors due to bed shortages. The buildings and equipment was either state of the art or rather past its best. You can see their wonderful ground breaking work here.

They provided a health and care service. People travelled to SIUT from all over Pakistan because they knew they would be seen, and helped. As with the NHS, the demand was unrelenting.  Whilst in the UK there has been a 30% increase in people pitching up at A&E departments, 30% of all attendees don’t present with an immediate need for emergency care. If people’s expectations are that’s where primary care can be found, then service providers and commissioners need to respond to that. Does this mean we need more GPS? maybe - is a different kind of primary care required? absolutely - should this include hospitals? probably.

We also need to increase what is done in providing Personal, Social, Health and Economic (PSHE) education. In various forms and to different levels, this is currently provided in schools in an attempt to equip young people with the knowledge, understanding, attitudes and practical skills to live healthily, safely, productively and responsibly. Much more could and should be done at other points of peoples life journey to reinforce the start well, live well age well approach to health promotion and the need to reduce demand for health care. It won’t make a difference tomorrow, but that shouldn’t stop us from trying.

Sunday, 8 January 2017

Do Chickens have ‘Whizzy’ brains and/or ‘Sticky’ thoughts?

In her latest blog, my fellow blogger Lynn Findlay shared her idea of what she described as ‘whizzy’ thinking – you can read her blog here. Lynn describes a way of being that many of us will recognise when thinking about our everyday lives - I really liked her concept of a ‘whizzy brain’. As always, reading her ideas made me stop and reflect – not about ‘whizzy’ thinking but what I want to call ‘sticky’ thinking. For me ‘sticky’ thinking best describes those thoughts that lurk at the edge of our consciousness. Thoughts that we keep coming back too, on which we ponder for a while before moving to whatever else is occupying us. ‘Sticky’ thinking doesn’t always result in a conclusion, but will draw you back into that ponder mode time and time again. 

Here’s an example. I am part of a large family and Christmas is always a time to share with other family members. 2016’s celebrations were a little different. After many family events, the last of which was a family party for 24 on Christmas Eve, W and drove up to Scotland to spend some time together. We wanted to be on our own, without family or friends staying with us. It was our choice to try and create some time away from folk. As it turned out we actually had very little time to spend without being in the company of others.

Of course it was lovely to be invited to friends’ houses or out for drinks, dinner or a party. It just wasn’t what we had planned, and the desired solitude and quietness were hard to come by. There is always next year. However, for many people, solitude and quietness are not desirable things. Recently published research from Age UK reported that 500,000 people over the age of 60 will often spend each day completely alone, with no interaction with other people. They also report that a further 500,000 people often do not see or speak to anyone for 5-6 days a week.

That is 1 million people in the UK who are profoundly alone, many of whom are likely to be enduring the pain and suffering of loneliness, depression and who will also be at a much high risk of requiring hospital care. Age UK have a great programme aimed at combating loneliness, but there is much more that needs to be done. My ‘sticky’ thinking was around reflecting on what I could do to help. One group I admire immensely when it comes in tackling loneliness of the older person is HenPower. Read about their fabulous work here.

As regular readers will know I have a bit of a thing about hens, and regularly claim to have the world’s greatest collection of all things chicken. Readers might not know, that I am just 517 working days away from retirement. I’ve started looking at what the next stage of my life journey might involve. I have wondered if there is something I could do that brings together my experience as a mental health nurse, a researcher, my love of chickens and being a chicken keeper, and a desire to make a difference. It’s within this contemplative space that my ‘sticky’ thinking has occurred – I know there’s something there, but I can’t quite see it.

It was my love of all things chicken that led me to read about the Someone Project, a programme funded and carried out by the Farm Sanctuary in the US. The Someone Project was featured last week in many UK newspapers when their latest research into hen behaviour was published. The research showed that hens are capable of greater logical reasoning than children, have distinct personalities and can even exhibit Machiavellian behaviours. They have a sense of numbers and appear to do simple arithmetic. They can exhibit self-control, and self-assess their position in the ‘pecking order’. Both of these characteristics are psychological indicators of self-awareness – although there will be some readers who find the notion of chicken psychology a little strange. 

Disappointingly, what the research report didn’t describe was whether hens have ‘whizzy’ brains or ‘sticky’ thoughts. But there is a big clue in the telling of Symphony and June’s story. They are 2 hens who are part of the Someone Project. You can read their story here and see what you think .

Sunday, 1 January 2017

Why Getting and Keeping Fit in 2017 Might Be a Bit of Struggle

Happy New Year to one and all! I hope that you achieve everything you set out to do in 2017. Remember it’s often better to adopt a glass half full than a glass empty outlook on life; and that smiles and hugs are very powerful when it comes to making a difference to people's lives. Father Christmas brought W and I a 'fitbit' this Christmas, possibly with the intention of trying to get us to make a difference to our lives. W immediately opened hers, downloaded the app and had 'earned' her first Urban Boots badge before lunchtime.

And its not just Father Christmas who wants to make a difference - coincidentally, Public Health England reported what they described as a health crisis last week. It appears that desk jobs, fast food and the daily grind are having an adverse impact on the middle aged. 8 in every 10 people aged between 40–60 are either overweight, drink too much or get too little exercise (or all three). Forget Generation X or Z, this group are now being referred to as the 'sandwich generation' – which is nothing whatsoever to do with cheese and pickle or a BLT. The 'sandwich generation' are often those looking after ageing parents as well as their own children. 

Even without the responsibility of child and elder care, many people in this age group live a life that is increasingly busy and demanding. There can be very little time to take exercise and or eat properly. Tiredness can lead to exhaustion, mental health problems and unwise decisions over how much alcohol consumption is good for you. It appears we are living longer but for a growing number of people, they will experience poor health because of the problems caused by the lifestyle choices they make.

Thankfully I am no longer middle-aged, and at my age I think one should always approach these ‘getting fit’ regimes with a modicum of caution. I lost count of the number of friends and colleagues who did themselves no end of harm, getting and keeping fit last year. I think my more cautious approach is possibly a good thing for me. If you want to find out what might make a difference to your health and wellbeing, you can try this on-line assessment here. Over a 1 million people have done so and many are already benefiting from changes to their lifestyle they are have made.

As for me, well I can share some of the promises I have made to myself for the New Year: I will always drink my single malt whisky only with water drawn and bottled from a Norwegian Fjord; my eggs will need to come from free range, organically reared Croad Langshan hens; and the accompanying chips deep fried in pure coconut oil; all other vegetables should be shredded using a Kai Shun Michel Bras mandolin; I won't eat bread unless its sprouted bread and comes complete with a verse quoted from the Bible (see Ezekiel 4.9). In future, in terms of making sure I get enough roughage in my diet, I will ask for my grapes to be served unpeeled.

Exercise is equally as important as diet. I will continue to walk every day with Cello my dog, and run my fingers through what’s left of my hair. The Elephant Bikes W and I got for Christmas remain warm and dry in the garage (it's promised rain every day since I got them here), but 2 people in Malawi who will have also each received a bike, are able to ride theirs everyday. And I am being severely exercised by trying to work out how to get my 'fitbit' out of its box and set up. 

Of course some of the above is said with tongue in cheek (well not the grape bit…) - this first posting of 2017 is my contribution to starting the year by hopefully putting a smile of people’s lips. I haven’t talked about the year that was 2016. For many people it wasn't always a good year. However, I did want to mention the story last week published in the Indy100, about Dr Donald Henderson. 

Donald Henderson died on August the 19th 2016. In a year of an unprecedented number of celebrity deaths, his death was barely remarked upon. Yet his impact on the world and the difference he made to many others is almost immeasurable. His lasting legacy arguably outshines the combined achievements of the many pop stars, actors and authors who were reported on following their deaths during 2016. The work Donald Henderson led on resulted in the eradication of Smallpox in 1977. This was the first human disease ever to be eradicated. A hugely important achievement as in the 20th century alone Smallpox was responsible for some 500 million deaths worldwide. For me, he really was the kind of person I would have liked to have sat next to at a dinner party.