Revolutionary thinking in a world embracing devolutionary action

The last time I was on TV was Wednesday the 25^th February 2015. In fact I spent much of that day giving TV and radio interviews which was a surprise to me. It was an even bigger one for my friends and family who turned on their TV’s only to see me on the news! That weekend I wrote in my blog that it had been such a perfect day. The reason I appeared on radio and TV was to comment on the ‘leaked’ news, which had been sent by over eager Manchester Councillors to BBC Radio Manchester. This was the news the signing of a Memorandum of Understanding, described as a ground-breaking deal, for the Devolution of Greater Manchester, was due to happen later on in the week.

A researcher from BBC Radio Manchester contacted me very early on that Wednesday morning and said could I come and give a live interview for their 07.00 news broadcast. I said yes and then spent a fruitless 15 minutes on-line trying to find something, anything about what has become to be known as ‘Devo Manc’. Now I am pretty good at digging out information, but in that 15 minutes I found very little. The researcher had been vague in his description of what he wanted me to speak about, but he did say it was about bringing together health and social care services across Greater Manchester.

I have long been a promotor of integrated health and social care so felt I could at least offer a view as to what the benefits might be if that is what ‘Devo Manc’ turned out to be all about. I knew that in 2011 the first combined authority in England was formed (made up of all 10 Local Authorities across greater Manchester). I also knew that the 12 Clinical Commissioning Groups (CCG) had, in 2013, formed into a Greater Manchester CCG Association. And of course I knew that the then Chancellor (George Osbourne) was personally backing the creation of the so called NorthernPowerhouse. All in all I felt relatively confident.

The reality was something different. Many of the interview questions I was asked on that day were about the political implications of the 10 Local Authorities gaining control of the £6 billion health and social care budget – the question I was most asked was whether I thought hospitals would close as Local Authorities used the money to spend on other activities. Some 2 years on, I still get asked that question as organisations move ever closer to achieving full integration of the commissioning and provision of health and social care. However difficult the task has been, the 37 NHS and Local Authority organisations across Greater Manchester, who together employ some 100,000 people, are now beginning to work together more effectively.

I think there is a way to go yet, but the emphasis is shifting (very slowly) towards both promoting health, and in providing health and care services differently, and often doing so closer to people’s homes and communities. In partnership with others, there appears to be more innovative thinking over what emergent technologies can offer in terms of cost reduction and the maintenance of quality services. In this context I can also see a glimmer of an approach that is definitely more focused upon people and places and not organisations.

I hope the same will be true for the ‘Devo London’ deal (described as both ground-breaking and a landmark deal). The announcement was made on the 15th Nov, but I only saw it early last week. I’m probably more Northern centric in my reading of news. Over a 100 organisations have been working together in developing the concept prior to the launch. Work on pilot schemes to illustrate and provide evidence of what might be achieved in working closer together has been ongoing for some 18 months. The early outcomes are impressive and encouraging. What makes this devolution different to the Manchester one is the availability of funding through the release of NHS owned land and property to fast track the scaling up of these pilots.

Not unsurprisingly, the NHS is a major landowner in the capital. The estimated value of this land and buildings is said to be more than £11 billion. Many of these assets are not used effectively, and 13% of community based buildings need rebuilding and 51% need refurbishing. The plan is to release the money raised through the sale of surplus assets to both create ‘fit for purpose’ health and social care resources in the community. and provide opportunities of for more housing developments. What it might mean for those living and working in London can be seen here. It looks to be a very ambitious plan, but I believe it is one that can be achieved. 

Perhaps Parliament itself could learn some lessons from the Manchester and London devolution initiatives in acknowledging the benefits of working together. Last Saturday (18th Nov) saw some 90 MPs sign a letter asking the Prime Minster to set up a ‘cross-party’ convention on the future of the NHS and social care in England. What they wanted was for the current Chancellor to address the short term pressures in the health system in his budget (something he subsequently did) and for the Prime Minister to establish a cross-party process to develop longer term solutions. Now it can't be just me who thinks creating such a group and a way of non-partisan working would be a great idea – after all its not really such a revolutionary thought in a world that is enthusiastically embracing devolutionary action.

Imagine a hospital without beds – please have mercy on us!

Consideration of how and why we communicate featured in my thinking last week. My interest was first sparked by the story published in the Independent about a computer hacking group with the improbable name of Di5s3nSiON. They had been hacking into the Isis terror organisations online site. Their aim was to disrupt and if possible, close down the extremist propaganda site – as they say #stopthewords. Isis responded by putting in place what they described as ‘stringent security measures’ – boasting their web site could no longer be hacked.  It took Di5s3nSiON just 3 hours to once again break through these new security measures and reveal some 1800 email addresses of those subscribing to the Isis site. The digital battle of words continues.

Later in the week I was also involved in a ‘battle of words’ – or rather a battle ‘over’ words. As I described in last week’s blog, I’m doing some work with the NMC on the development of educational proficiencies for future nurses. Last week’s work focused on the skills nurses will need to demonstrate at the point of registration, and procedures they will need to be able to undertake from day one as a qualified nurse. It is an iterative process. Drawing on wide consultation and with the benefit of access to expert knowledge, propositions have been created which as a group we challenge. We do this remotely through teleconferencing, with each teleconference lasting 2 hours. Now I like to look into the eyes of whoever it is I am speaking with, and teleconferencing doesn’t allow you to do this. Even Skype and Facetime have their limitations in this regard. Ironically, last week’s teleconference focus was on the skills of communication and on the context and media used. Given that we were looking at what the graduate nurse in 2030 might require in terms of such skills, it was difficult to move our thinking from the here and now.

As can be seen from the Isis example, social media can be an extremely powerful way to communicate and influence others. However it is not the only way. Last week I was able to catch a glimpse of something very different in how health care might be provided in the future using digital technology, and communication media in particular. My glimpse came from a report about the work of the Mercy Virtual Care (MVC) Centre, in St Louis, US. It has a great deal that is similar to most UK hospitals - it has nurses, doctors, and other allied health care professionals. What it doesn’t have are beds.

The doctors, nurses and other staff do all the things you would expect them to do in looking after their patients, monitoring vital signs, and looking at the results of diagnostic tests. Their patients are elsewhere. Many of them are in their own homes, others are in specialised units distant from the MVC centre. Like the UK, the US health policy see's health care providers moving services closer to people’s homes. Unlike the UK, the US system is more explicitly linked to payments at the point of care. The move in the US is towards paying hospitals to keep people healthy and away from entering their front doors.

In the UK we have a health care system that waits for patients to pitch up at the hospital, an approach that increasingly causes problems – just think about the A&E crisis we are currently experiencing. The effective use of new digital technology allows health care professionals at the MVC centre to monitor those with complex and long term conditions to such an extent that they can advise on early interventions and reduce un-necessary hospital admissions and lengthy stays. The MVC centre also works closely with other hospitals. Yes we will still need some provision for those involved in trauma, needing an operation, delivering a baby, receive intensive care and so on, but increasingly care will move towards those with long term health problems such as diabetes, heart failure and potentially life shortening diseases such as cancers. In the future I don’t think we will have the huge hospitals we have today. In the future health care will be provided from small units, with speciality health care services provided centrally. 

The MVC centre’s approach could provide the ‘organisational glue’ to ensure that patient deterioration is picked up more quickly and accurately, allowing those working in close contact with patients more time to provide person centred care. There is a paradox in this approach however. The health care professionals at MVC report a very close (almost intimate) relationship is possible with the patients they have contact with. But the one thing they miss is being able to put their hand on the patient and say ‘my name is…’ – and in our NMC teleconference last week the group put ‘touch’ alongside listening and speaking as important aspects of skilled communication in developing effective therapeutic relationships. 

You too can train in approaches to suicide prevention: it’s not just for nurses

One of the advantages of being both retired and able to use digital communications technology is that I can now attend meetings from the comfort of my living room. Fortunately the 2 teleconferences I took part in this week were audio only, so nobody could see me sitting there in my shorts and t-shirt, my hair looking like I had been dragged through a hedge backwards (we have strong winds up here in the North!). The teleconferences were a wonderful way to be able to participate in what is being called the Consultation Assimilation Teams (CAT) for the Nursing and Midwifery Council (NMC). CAT are sub-sets of the NMC Thought Leadership Group (TLG), which is a group I have been a member of for the past 2 years.

The work of the TLG has been to look at the scope of practice for a graduate nurse in 2030 and what might be the most effective way of preparing them for that role. It has been a great group to work with. There are representatives from all 4 nations of the UK. The TLG is made up of academics, senior nurses, and student and early career nurses. The membership of the group spans all areas of health and care practice. It has that tangible depth and richness of quality and confidence that comes from a collective experience reperesnting 35 years of nursing practice, research and education.

The CAT teleconferences provide an opportunity for the TLG to revisit the draft standards of proficiency. These are what potential nurses will need to demonstrate they have met in order to gain registration and be considered a capable and safe practitioner. The proficiency standards have been grouped under 7 headings which describe the key components of the roles, responsibilities and accountabilities of registered nurses. It is anticipated that at the point of registration, graduate nurses will: be an accountable professional; promote health; assess needs and care plan; provide and evaluate care; lead nurse care and work in teams; improve safety and quality of care; and coordinate care.

These proficiency standards are just one of a suite of interrelated pieces of work being undertaken by the TLG. Other strands of work include: standards for education and training (with particular emphasis on how learning will be assessed); the requirements for future pre-registration and prescribing programmes; and medicine management. It is a very interactive process, with much consultation being undertaken across a wide variety of stakeholders. Last Tuesday I travelled to London to join the rest of the TLG for a day of consolidation and up-dating on progress so far. It was an exciting day, and it was good to see the data that was gathered through the consultation activities.

However, unlike the teleconferences, attending the TLG required a train journey to London, which was fine going down. Later that day and some 10 mins after leaving London to return to Manchester, the train stopped and didn’t move. After some 30 mins we were told by the train manager that sadly there had been a fatality in Bletchley, just outside Milton Keynes and as a consequence we could expect a great deal of disruption to our journey. Eventually we did re-commence the journey, which instead of taking 2 hours actually took nearly 5 hours.

Of course the temporary inconvenience we as passengers experienced on the night would be nothing compared to the distress, pain and shock the family and friends of the person who died will have to deal with. They will have to deal with it for the rest of their lives. My thoughts were also with the train driver and those from the emergency services who attended the scene. I don’t travel to London very often these days, but this is the second time this year the train I was on has been delayed because of a fatality. Sadly it’s a fairly common occurrence. The latest figures (2015/16) for the number of overall fatalities on British railways was 297, and although these data won’t be officially updated until December, so far the 2016/17 figure is 276 deaths. 

The person who died last Monday did so by suicide. 252 of the 297 deaths on British railways in 2016/17 were as a result of suicide. Each of these deaths is very sad, and each will have its own circumstances and complexities. Sadder still is that 4 people have chosen death by suicide at or near the Bletchley Station in the last month and 7 people have died in this way since July. Reassuringly, work is being undertaken to address this problem, and large numbers of Network Rail staff and Transport Police are attending a suicide prevention programme run by the Samaritans. See here for more information.

The programme teaches rail staff how they can respond if they see someone looking vulnerable in or around the station itself, a railway crossing bridge or the general station environment. They are taught what to say and how to start a conversation. There is much evidence to support the notion that talking is often the first and important intervention in saving someone’s life is such a situation. It is a simple step to take, and for those people perhaps fearful of saying the wrong thing, the Samaritans programme has proven to very helpful in raising self confidence and challenging the stigma sometimes associated with dealing with suicide. I would also suggest that the programmes information is helpful for all of us too, and that will, in time include the graduate nurse of 2030. 

It’s not just the chattering classes that should be concerned about the NHS – it’s all our problem.

I very much enjoyed taking part in last week’s #WeNurses twitterchat. Next year sees the 70^th anniversary of the creation of the NHS. See here for a brief public information broadcast celebrating the birth of the NHS, which was made at the time. Given this focus, the overall question explored in the twitterchat was: The NHS, What would you do? During the 60 minutes of tweet conversations, contributors considered what makes the NHS special; why we might need to be concerned about the future of the NHS; what they would do if they were Secretary of State for Health; and what the NHS might look like in another 70 years’ time. It was a lively chat, and you can read the twitterchat summary here.

Not surprisingly, there was a lot of high expressed emotion during the chat with health service managers and politicians responsible for funding, coming off worse. I say not surprisingly for a number of reasons. Both groups are easy targets, and there is a grain of truth in the claims that we have too many managers and there is not enough money. Last week the independent charity, the Kings Fund reported that 51% of all NHS Trust Finance Directors thought the patient care in their area had got worse over the last 12 months. Less than 45% felt they would meet their financial targets this year. As the Kings Fund pointed out, the NHS is in a precarious position heading into the winter, with all the problems that is likely to bring.

Already many Trusts are not meeting the four hour A&E target. There are now 4.1 million people waiting for treatment and emergency admissions are 3% higher than this time last year. Likewise what was noted in many of the twitterchat tweets, workforce issues are also adding to the problems and challenges facing the NHS. It’s getting harder to recruit nurses in many parts of the UK and some medical specialisms are becoming very difficult to recruit into. The days of recruiting nurses from overseas particularly Europe are long gone. Normally up to 10,000 nurses a year come to work in the UK from other European countries, this year that number has fallen by 90% to just 1000 nurses. Likewise many of those nurses recruited over the last few years have started to return to their home countries. The NMC reported that 67% of those nurses recruited have now left the UK.

Sadly many UK nurses are also leaving the profession. Some 29,000 left the NMC register in the year to September 2017, which is an increase of nearly 10% on the figures for the same period in 2016. I am not seeking to revalidate my registration next year. This is not because I am experiencing, directly, the pressures of being on the front line of practice, I am simply retiring. And I am not alone. It has long been recognised that nursing and midwifery is an ageing profession, with significant numbers of nurses on the register now reaching retirement age. Age UK reported in July this year that there are now 15.3 million people in the UK over the age of 60. This number is expected to pass the 20 million mark by 2030. Nearly one in five people currently in the UK will live to see their 100th birthday, and this figure includes 29% of people born in 2011.

Perhaps what is not so readily recognised is that there is also a significant increase in those nurses on the register who are choosing to leave before they reach retirement age. The NMC reported earlier in the year, that when those nurses who retire aged 60 are excluded from the numbers of those that are leaving the profession, the average age of all others leaving the register is now 51 years. The numbers for those under the age of 40 who are choosing to leave the profession is particularly noticeable. 

Last week also saw the emergence of another significant element in this workforce and funding perfect storm. The Health Service Journal reported on yet another hospital trust replacing qualified and registered nurses with Nurse Associates. I have no doubt others will follow. There is plenty of good evidence that reducing the nursing skill mix by adding nursing associates and other groups of assistive nursing staff contributes to preventable deaths; has a negative impact on the quality and safety of patient care; and ironically contributes to hospital nurses shortages – see some of this research here. Back in 2016, Health Education England’s Director of Nursing, Lisa Bayliss-Pratt assured the nursing profession that this wouldn’t happen. Secretary of State for Health, Jeremy Hunt announced in Oct that another 5000 nurses associates would be trained in 2018, and a further 7500 in 2019. 

As my friend and former Dean at Oxford Brooks University, Professor June Girvin noted last week, ‘Nursing has sleep walked into the dismantling of the profession. Without blinking an eye’. And sadly I don’t think there are any easy or quick solutions to the situation we find ourselves in – over time the workforce issues will get better, but services will need to continue to change and become more integrated, and people will need to take greater responsibility for the maintenance of their own health and wellbeing.