Planting 'idea seeds' for improving mental health care

Once upon a time I would read every one of Roy Lilley’s blog postings. He is a very insightful commentator on health and social care in the UK. He is a very successful leader, educationalist and a great public speaker, and he is much in demand. I think over the past few months, as the Black Dog of depression began to be my companion I got out of the habit of regularly reading his work. I began to find the somewhat acerbic and negative narrative, often aimed at politicians and health service managers, wearying. However, I am sure my decision was influenced by where I found myself in the world, not really a consequence of Roy’s writing, which is much admired by many.

One of whom is Warren Heppolette. He is the Executive Lead for Strategy and System Development at the Greater Manchester Health and Social Care Partnership (GMHSC). It is the GMHSC Partnership, made up of NHS Organisations and Councils, that is leading the £6 billion devolution of health and social care budgets in making a difference to health and wellbeing in the city and region. They are doing a great job and are moving at a pace – and are starting to provide some excellent examples of what integrated care and population health could look like.

So when someone like Warren tweets that he thought one of Roy’s blogs last week was one of the best he’s read, I was compelled to have a look, and I am glad I did! The blog dealt with a mental health service in Grimsby. It was something Roy had experienced through visiting a garden centre run by the mental health service. Without wishing to sound disrespectful, I don’t think I would ever have associated Grimsby with innovation, but what Roy described was the hugely innovative and creative work of a social enterprise called NAViGO:

‘They own apartments, create communities, and piece by piece, carefully reassemble the components of shattered lives and glue them together with skills, care, attention and tuff-love… …the acute team is the community team, is the crisis team. I couldn’t tell who was health and who was social care, who were staff, clients, partners and people working towards recovery… …services entwined with people’s lives, families, hopes and futures. And it works.’

Like Warren, I was also impressed with the description of how this service has developed. Many years ago, we had some folks from the precursor to the NAViGO service visit the University and it was possible even then to see what an exciting journey the service providers, carers and service users were on. That Warren recognised the importance of this work was also good to see, particularly as on Friday he published the GMHSC plans for the Transformation of Mental Health Service: Next Steps.

This document sets out the plans to make a £134 million pound investment in not only meeting the national mental health care targets, but in so doing, also look at new and innovative ways of improving the mental wellbeing and resilience of the GM communities. There are plans to ensure that physical and mental health programmes and approaches are to be more closely integrated – and with Olympic Gold Medalist Chris Boardman being appointed as the GM Cycling and Walking tsar (Commissioner), I have great hopes that we can do something differently.

Effective 24 hour access to help and support for children, young people and adults requiring immediate care and treatment are planned, as are improvements to the early intervention service provision. All of which will ensure that every £1 spent in prevention and early intervention will save £15 in the provision of ongoing health service costs for people experiencing mental health problems. Likewise, improvements to mental health care in the criminal justice system, particularly for those in prisons are outlined. 

It is a great document, full of hope and determination. Although the report doesn’t specifically mention gardens, or horticultural therapy, care farms or anything remotely similar I am confident that my colleagues at the University will ensure these approaches are included in taking forward the GM mental health transformational plans for the future. So thank you Roy, thank you Warren for show-casing what (if we want it), could be a bright new future for mental health care in the UK.   

Missing in Action; and Missing the Action

Last week there were a number of places I should have been at, people I should have seen, conversations I should have had, and hands I should have held. It wasn’t a good week for me, and possibly, for others too. It was a week of poignancy and pain as well as some goodness. Last week was graduation week at the University of Salford. As long standing readers of this blog will know, when I was Head of School and then latterly a Dean, Graduation Day was both my nemesis and one of my greatest pleasures each year. It was always great to celebrate the success of our students, meet their family’s and wish them well on the next stage of their life journey.

This was me some 39 years ago (ringed in yellow) ‘graduating’ as a qualified nurse in Swansea. I was so proud to have survived the course, which unlike today, was not a graduate level programme. The ceremony back then was a very different affair from the graduation ceremonies that I have been part of over the last 11 years. I love being on the stage and the little boy in me likes dressing up. The pomp and tradition, the seriousness and celebration were tangible acknowledgements of the achievement every person gaining their degree has made. What I dreaded about the day was trying to pronounce the names of some of our students. I just found it so difficult to get my tongue around some of the pronunciations, despite hours of practice.

However, despite my tendency to mangle some people’s names, it always felt like a real honour to present the names of the students as they each received their award. My current role in the University has taken me away from this, and it is something I have really missed. Last year I had a kind of ‘walk on part’. As a member of the University Council I was asked to talk about the work of the Council and the Councils contribution to the future development of the University. It wasn’t quite the same. And this year I didn’t get to be part of any of the ceremonies at all.

Being part of celebration of the students success was a wonderful experience to share. But I guess inevitably, it was those students who I had the closest and most sustained relationship with that made my heart beat with pride for them at graduation. Most often these were my PhD students. This year 2 students, Duaa and Seham, both from Saudi Arabia, completed and were able to graduate. They had their struggles over their time with the University, but both eventually did very well. Seham, whose work looked at the stigmatising views and attitudes of mental health professionals held against the very people they should be caring for, was both courageous and powerful. She has already gained an influential position back in Saudi, and I am very confident that she will make a difference to their future mental health care services.

Due to poor timing, another of my students Ibrahim, also from Saudi, had his PhD viva last week, and got through with just minor corrections to attend to. I missed the viva and being there with him, a role carried out so well by my co-supervisor Celia. Ibrahim's work looked at the impact of total quality management approaches to the improvement of health services in Saudi. Again it was a very interesting piece of work that revealed the difficulties that many health service systems have in both measuring and improving the quality of care provided.

In the UK it is the Care Quality Commission (CQC) who are charged with both measuring the quality of care provided and recognising where services are outstanding or simply unacceptable. To me, the CQC have an almost impossible task, and arguably whilst some poor practices are picked up and addressed, the approach remains imprecise and challenged by the human element of the assessors. They are not my favourite group of people, and I say that from the qualified position of being on both sides of the quality assurance table.

I was reminded of this last week as my brother-in-law David became a patient at a local hospital – North Manchester General Hospital. In 2016, the CQC judged this hospital overall to be ‘inadequate’. This was a damming judgement of the services provided, see here for the full report. The reports ‘inadequate’ outcome prompted a neighbouring and ‘outstanding’ NHS Trust to take responsibility for bringing about improvement. The work is ongoing. One of the things I think the CQC often gets wrong, is that they miss the individual experience of patients. David’s care was exemplary. It was provided by knowledgeable health care professionals, who demonstrated their care in the most compassionate of ways. Yes there were issues (noise at night; ward transfers and so on) but overall he was treated as I would want to be treated. 

Sadly, after just a week of receiving treatment, David died in the early hours of Friday morning. I wasn’t there, but his wife and son were. They were treated with respect and dignity and when W got there shortly after his death, the nurses made the time to support and comfort the family. David was a larger than life man – in all senses of the word. He looked after his 2 sisters (Glenda and W) all his life, and his son and 2 grandchildren were the apple of his eye. The love of his life was his wife Jenny, someone he would have done anything for. David will be very much missed, and although his sudden and unexpected death is a great shock, I am glad at the end of his life he didn’t suffer, and proud that that the care he received from the NHS was absolutely outstanding. 

Depression and Duvet Days

Last week I finally managed to meet up with friend and long term collaborator Sue. We has been trying (somewhat unsuccessfully) to meet for the best part of 6 weeks, and it was so good to finally find a space to spend some quality time together. We have been writing and publishing for some 17 years, and we have relished getting our thoughts and ideas out there, editing books, writing papers, and of course presenting at conferences. It’s been great fun and I think together we have made a difference – I also like to think that we have also helped many others start their academic journey.

For some people, presenting their research, or their thoughts to a conference audience is a somewhat daunting experience. This is particularly the case for early career academics and practitioners, many of who, often feeling that nobody will be interested in hearing what it is they do in their day job. As Roy Lilly has so successfully demonstrated, so often what might be felt as being ordinary in the provision of health care can, and very often is, quite extraordinary. Whilst getting your words in print can be very satisfying, these days with more opportunities to put your thoughts out there and sometimes to a larger readership, my publication rate has slowed right down. However, I have always enjoyed the conference presentations, and Sue and I have presented over 90 conference papers between us over the last 17 years.

We both share a love of surreal images, and often our presentations contain very little words, just thought provoking images we use as cues to the paper being presented. It’s been our experience that people appear to become more engaged in what is being said, and tend to remember more of the paper than when the ubiquitous PowerPoint is used. I have never been nervous or anxious about presenting and very much enjoy being on the stage whatever the number of people in the audience, or the venue.

So I have been very surprised to have recently started to experience anxiety or panic attacks on fairly regular basis. It took me a while to recognise what these were and what was happening. I had described the feeling as being faced with utter desolation to my doctor, a feeling that happened mostly in the morning. I would wake up and everything would feel fine, I might even send out a few tweets, particularly to the #earlyrisersclub but then very soon I would be consumed a combination of physical sensations: hot flushes, sweating, pounding heart, pins and needles and psychological sensations: racing thoughts and thinking about the same situation over and over again, a sense of dread, feeling restless, and tense. In the UK 1 in 10 people will experience a panic attack, and  5% of the UK population experience anxiety attacks, and it affects twice as many women as men.

My response to these feelings and sensations was to pull the duvet over my head in an attempt to block everything out. Which of course didn’t work at all. Usually after about 10 minutes these sensations would begin to ease leaving me feeling very down and uneasy for a couple of hours. Eventually my mood would lift somewhat. It was only when I wrote the feelings and sensations down after one of these episodes that I realised it was an anxiety attack I was experiencing. There are a number of powerful stresses in my life currently, resulting as some readers might know, in a current state of depression.   

Thankfully, just as when I confirmed that diagnosis with my GP and could start to receive treatment, realising I was experiencing anxiety attacks has allowed me to start to deal with them, and begin to address the stress that lies at the root cause of the anxiety. Not bad for a Professor of mental health care. And I think there must be a paper to be written here and a conference to find where it could be presented!

For some it will never be the ‘Darling Buds of May’

In 1892 the High Rid Reservoir was constructed as part of the need to supply water to the cotton industry and the local population. It lies just some 3 miles outside of Bolton, which in 1838 was the second town to be incorporated under the Municipal Corporations Act, and did so 12 days before Manchester, that other somewhat famous North West place did… ...just saying. High Rid is some 7500 steps (5.3Km) from my Bolton House front door and back, and it is one of my favourite walks. Last week on my walks I saw new generations of ducklings in abundance, the Sun had Her hat on most mornings, and as Cello and I walked, we were accompanied by dancing damsel flies weaving their intricate patterns along our pathway.

Walks around High Rid last week were also punctuated by the shrieks, screams, shouts and laughter of children having fun on the water. The owners of High Rid, United Utilities, allow Bolton Council to run a range of activities for children and young people – including canoeing, kayaking, raft building, sailing, in fact all water sports other than swimming. It was great to see the children having fun, doing something physical, outside and being in the company of other children, all of which is good for the physical development and emotional well-being. One of my neighbour’s sons attended such a session last week and he was so excited to have the opportunity, and he loved it.

However, there were a number of stories last week which didn’t paint such a rosy picture. The one that stayed upper most in my mind was a series of reports from the Children’s Commissionerfor England. The reports draw on data and information held by a range of government departments, agencies and third sector organisations. The reports make for a very hard read and present some very shocking statistics about the number of children in England living in vulnerable situations. The reports contain a huge amount of granular detail, too much for this blog. However, some of this information I found staggering, and I regularly read up on the research in these areas.

What I was aware of was that children and young people make up nearly 25% of the population. 40% of all primary care activity relates to this group. Nearly 3 million children aged between 0-17 are in contact with tier 1–3 child and adolescent mental health services each year. Such services include GP (primary care), services in schools and some specialised services. Of these 15% have a long term condition, 6% have a disability, and that 50% of all mental health problems in adulthood start by the age of 14. 50,000 children experience child abuse each year. Over 500,000 children are so vulnerable that the State has to step in with nearly a 1000 children being cared for within the criminal justice system and in secure accommodation of some sort. Some 60,000 children go missing each year and nearly 50,000 children aged 10-17 are involved in gang related activity. And there are 700,000 young people who are carers. All of which is what has been reported. The real statistics might be much higher of course as much of this activity happens ‘under the radar’.

What I didn’t know was nearly a third of children aged up to 5 years of age have significant tooth decay problems, or that there were some 46.000 emergency admissions for children with lower respiratory tract infections,  or that  some 130,000 young people between  ages of 15–24  were tested positive for Chlamydia  - and generally for children 15 and above, they seemed to be in a high risk group, with some 20% of those engaging with risky behaviours including smoking, drinking, poor diet and poor physical activity. There were over a 100,000 hospital admission due to unintentional and deliberate injuries in children aged 0–14, nearly 50% of which were aged 0–4. In addition there were some 50,000 admissions following self-harm in children and young people aged 10-24. Nearly 12,000 children had parents receiving drug treatment, and 15,400, children where parents were receiving treatment for alcohol abuse.   

The disturbing statistics go on and on – sadly. As a Father of 5 children, and now 10 grandchildren I felt humbled and ashamed in reading these reports. More so as I come from a generation that openly declared we would not bring our children up as our parents did. I love my parents, but in many ways I think I am very different to them. But they loved, cared for me and they did so unconditionally throughout my childhood, and continue to do so now albeit some 60 years later. And if asked, I hope my children will say the same about me.

A stroll down a Welsh memory lane

In June 1984 I left Wales to start a new life in the North West of England, Manchester to be precise. I have been here ever since. I had trained as a nurse in Swansea, but lived in a little village called Pumpsaint, some 40 miles away. In those days the hour long journey was through the Welsh hills and valleys almost until you got to Swansea. Most of the time this was a journey that helped prepare me for the day, or provided time and space at the end of the day when coming home.

I had a little small holding in Pumpsaint, keeping a herd of milking goats, a small flock of Jacob sheep, chickens, ducks, geese, and even peafowl. I grew all the family vegetables, made goats cheese, brewed beer and wine and baked homemade bread. I fattened turkeys to sell at Christmas, and worked in the forest cutting down Christmas trees to sell. Four of my 5 children were born there, learning Welsh in a small village School. For a short period after gaining my qualification as a nurse and starting to practice I worked in a local agricultural blacksmiths, a place where the work included shoeing horses to repairing huge bulldozer blades and everything in between.

I eventually went back to work as a nurse in the local hospital, Allt-Y-Mynydd. This was a small hospital for people with learning disabilities, and it was a great time to be working in this area. At a policy level, the all Wales community care initiative was being enacted and this was aimed at moving all of the people receiving care for learning disabilities into assisted independent, community based care environments.

Allt-Y-Mynydd hospital was an old sanatorium, perched on top of a hill in the midst of the Brechfa forest. The hospital was just outside a village called Llanbydder, famous for its horse fairs, and where once there was a connection to the Manchester and Milford Railway! I joined as a staff nurse, but quickly gained promotion as Charge Nurse, an achievement marked by my not having the Learning Disability qualification, and only being on the register as Mental Health Nurse. However, I had an absolute conviction that we could carry out the policy and make a difference to the lives of the residents. 

Allt-Y-Mnynydd Hopsital is still there, now a tastefully modernised care home, and almost unrecognisable in terms of the facilities and the care provided. During my time in the hospital we very successfully prepared, moved and supported most of the residents out in to local community based homes. I was reminded of these memories as last week was Learning Disability week, 2017. There are some 1.4 million people with a learning disability in the UK, nearly 200,000 of whom, are children of school age.

Whilst it was great to hear so many very positive stories about learning disability services and in particular social care services, last week also saw the publication of a report on research undertaken by researchers at the University of Lancaster. It has a snappy title ‘A Trade in People: The inpatient healthcare economy for people with learning disabilities and/or Autism Spectrum Disorder’, but the findings were rather grim. It found that many people with learning disabilities had become commodities in a health care industry driven by profits. It seems the UK government spent some £477m last year on keeping just 2500 people in hospital with more than 50% of these beds being provided by the private sector. It is a trend that is growing. 

The consequence of this approach is that often individuals can be placed in geographical locations many miles away from their family home with families facing long and expensive journeys in order to maintain contact with their son or daughter. Sadly, those detained in private care services are also more likely to experience an assault and be restrained compared to those receiving care in a NHS unit. The report also found that that the cost of a care package (similar to those we put in place all those years ago in Wales) to move people back into their community could be prohibitively expensive for local authorities to contemplate – thus perpetuating the problem. It is such a sad indictment that some 33 years after my time in Wales we are still treating people in this way.