The Good, the Bad and the Hope that's to be found in all of us

There were a number of people last week, who for good and bad reasons, made me stop and think. Some of the people, and some of the situations they were in, had both ‘good’ and ‘bad’ aspects. For example, on the bad side of the ledger, there was Boris Johnson’s demand for an extra £100 million a week for the NHS, and the suggestion that we should build a bridge between the UK and France. Some might have found these suggestions vaguely funny. I didn't. And I didn't think there was anything funny about Theresa May’s use of the term ‘child pornography’ when she spoke in Davos last week. Possibly drawing on a well-intentioned perspective, she called on social media organisations to take more proactive action over their platforms being used to promote terrorism and ‘child pornography’. Of course, most of us would think that is a good thing.

However it is never ‘child pornography’, it is always child sex abuse*.

In another mixture of good and bad, I read the story of Larry Nassar, the disgraced US gymnastics team doctor who received his sentence (175 year imprisonment) for his abuse of female athletes in his care. He was already serving a 60 year sentence for his sexual abuse of 7 girls. Last week he attended a sentencing hearing, at which a further 156 girls and women came forward to speak about the abuse they had suffered under the guise of Nassar giving them medical treatment. The ‘good’ element in this story was the judge, Rosemarie Aquilina. She allowed each of these witnesses time to talk about the impact the abuse had on their lives and their wellbeing. The extracts shown on television made for hard viewing, and I cannot imagine what it would have been like to actually been in the courtroom.

A number of the young women asked Nassar’s for an apology, which he did, albeit in way that appeared grudgingly and insincere. Some of the young women talked of forgiveness, something I found incredibly brave to do. In another story last week, which also involved the abuse of a professional relationship, it would be impossible for the perpetrators victims to offer forgiveness. All but 2 of victims are now dead. This was the case of Niels Hoegel, a nurse working in Germany, who is currently serving a life sentence for killing 2 patients and the attempted murder of 2 more. Last week, he was back in court, charged with the murder of 97 further patients between 1999 and 2005.

During his original trial he said he ‘enjoyed’ the feeling of giving his patients a cardiac crisis and then being able to resuscitate them. Hoegel used a variety of drugs to cause the cardiac crisis and in resuscitating them. It was these drugs that allowed for toxicological examinations of some 500 patients and the case notes of hundreds more. The German authorities also exhumed 134 bodies from 67 cemeteries as they gathered evidence. In shades of Mid Staffordshire, the German police have said that due to the local health officials prevaricating over whether to alert the authorities or not, Hoegel could have been stopped earlier and lives saved.

The last person who caught my attention last week was Tessa Jowell. I watched in awe, the coverage of her speech to a full house of members in the House of Lords. I thought her speech was powerful, poignant and totally compelling. At the end of her speech, the entire crowded House of Lords rose to their feet and applauded her. The standing ovation was long lasting and was almost without precedent. At the end of May last year, Tessa Jowell discovered she could not speak.  A few days later her doctors diagnosed the problem was a brain tumour, a glioblastoma multiforme. The prognosis is not very positive. She had the tumour removed 2 weeks later. She is shortly to set off to Germany to receive  a new and revolutionary immunology therapy. 

Her speech was aimed at raising awareness of the fact that in the UK, we have the worst survival rates for cancer than anywhere else in Western Europe. She called for both more international co-operation and greater access to ‘adaptive trials’. These are clinical trials that allow a person to try more than one treatment if one doesn’t appear to be working. And they can do so even if they have not completed their first trial. This approach to research is both good and bad. In those where the cancer clock is ticking it is perhaps not surprising that people might want to try all available treatments, whether proven and approved or not. The down side is that such approaches breach the safeguards in place in developing new drugs, which are there to protect us all from ‘snake oil’ remedies and unrealistic expectations.

Tessa’s speech was also rich in emotional narrative. She drew on the Irish poet and Noble prize winner, Seamus Heaney, who just before he died sent the words ‘Noli timere’ (Latin for: do not be afraid) by text to his wife Marie. In her speech, Tessa said she ‘wasn’t afraid’, and ‘in the end, what gives a life meaning is not only how it is loved, but how it draws to a close’. She said her hope was that the debate she had started with her speech would provide hope for other cancer patients, ‘so that we can live well with cancer, not just be dying of it. All of us. For longer’. Which would be a good thing.

*If you have been affected by sex abuse (current or historic) the BBC have collated information and sources of support for children, young people, and concerned parents. 

Nursing Recruitment and Retention: Skating on Thin Ice?

Yesterday I saw the BBC’s advertisement for the forthcoming Winter Olympics. It was stunningly different and attention grabbing – well at least for the first time it’s watched.  All sport is a challenge but I think that the Winter Olympics are something special. Athletes have to not only be physically fit, expert and skilled in their chosen sport but must also contend with the unpredictability of snow, ice and the cold. Something I found to my cost last week. Not that I am winter sportsman, but simply my #WalkEveryDay was a challenge. I have never experienced icy conditions like it. It was literally not possible to stand up, let alone walk.

I was one of the fortunate ones. I didn’t have to commute to work, and didn’t need to be anywhere on any particular time. Up here in my part of Scotland we had a great deal of snow and 4 days ago over 200 drivers were trapped overnight on the nearby M74. Conditions were challenging indeed. It wasn't just for those keeping us safe on the roads by gritting, and clearing the snow, but for also for those responding to breakdowns, and the emergency services, who in all weathers and at all times, come to our aid whatever the cause. Ambulance services in particular were under great strain. Across England, the 10 Ambulance Services operate using a Resource Escalation Action Plan (REAP) which has a range of (1) indicating no problems through to (4) indicating extreme pressure and demand on services. Last week only the London Ambulance Service was at level (2), all the others had declared they were operating at level (3).

That said, the enormous challenges Emergency Departments have been experiencing throughout December and early January, eased marginally last week. The critical point of exchange at the ambulance handover to the A&E department showed some improvement. Whilst it’s still the case that 1 in 8 patients continue to experience ambulance handover delays, there was a reduction of 4000 (down to 12600) last week in those having to wait more than 30 mins just to get into the A&E department. Hospitals were reporting that bed occupancy was down from 95% to 94.9%, but this is still well above the recommended safe limit of 85%. So there is some way to go yet before we can feel confident that the surge in demand is beginning to slow down.

Unfortunately some of the media last week made great play that in its 70th year the NHS was facing a crisis like never before. Absolutely those on the front line, nurses, doctors, other health care professionals, support workers and volunteers have had to deal with an almost exponential rise in the demand for services. The Daily Mail, in its own inimitable and sensationalist way, reported on the possible consequence of these extraordinary demands on the wellbeing of the nursing profession – describing the current situation as the ‘NHS haemorrhaging nurses at the rate of 1 in 10’. The BBC also joined in. The facts are true – see here on the NHS Digital site – some 30,000 nurses left the NHS last year. Interestingly the statistics also reveal that the rate of those leaving the profession in percentage terms, hasn’t essentially changed over the last 5 years as the overall number of nurses has steadily risen over the same period.

What has changed is that the numbers of those choosing nursing as a profession have fallen. There is now a negative gap between those leaving and those joining the profession which might lead to some shortages in the near future. What I found challenging was the way the reports chose to deal in generalisations. Not helpful I felt. More pertinently, nursing staffing challengs in UK hospitals has been a reoccurring issue even before the NHS was created back in 1948. The reasons given for nurse shortages has been the subject of numerous governmental inquiries. These almost with out exception have blamed; poor pay, poor training opportunities, and in times gone past, the so called ‘marriage bar’.

Way back in the 1950s the most common shortages were in hospitals for the elderly, mental health and what we now know as services for those with long term conditions. In 1949 the Ministry of Health, the General Nursing Council and the Royal College of Nursing went to the Caribbean to recruit nurses. Over the next 20 years the British colonies (and former colonies) provided the NHS with many of its nurses. By the time I started my nurse training in 1975, it was estimated there were 10,500 students recruited from overseas, and 66% coming from the Caribbean.

The 1980s saw the NHS facing severe nursing retention and recruitment problems. Nursing as a career choice for young people had declined markedly. Changes in social aspirations and more generalised public sector financial constraints resulted in many new entrants to the job market seeking alternative employment opportunities. The abolition of work permits in 1983 for overseas nurses added to the difficulties. By the late 1990s, some 30,000 nurse were leaving the NHS every year (sounds familiar doesn’t it). Interestingly, they were said to be leaving because of perceived low pay and the unrelenting pressures of the job. Like the predictable unpredictably of the snow, ice and cold of winter time, planning, delivering and managing the NHS workforce will take the skills, confidence and experience of Olympic proportions. 

One Flu Over The Containing Nest

One of my childhood memories is of going to the local fish and chip shop, buying a portion of chips and a great big juicy gherkin to eat on the way home. The chips were always too hot to eat, and the vinegar from the gherkin always seemed to run down my arm. I’ve loved chips and gherkins ever since. And last week, I found myself standing in my local supermarket (actually its 21 miles away) looking at the pickle shelf with a view to replenishing my larder after the Christmas celebrations. As I stood there looking, I became aware of 2 women talking about flu.

I’m a researcher who has often drawn upon cultural anthropology as a way of trying to understand how people make sense of the world around them. I’m always keen to seize any opportunity to engage in an ethnographic experience. I felt a little like a participant-observer as I stayed where I was and listened to the conversation. Both the women appeared concerned over the growing number of news stories about flu. Neither of them wanted to have the flu vaccination, citing that it was ‘pointless, it doesn’t protect you against the flu so why bother’; they talked about ‘that girl’ who had died from flu and not only had she died, but she had done so in a hospital; and that ‘we always gets lots of flu at this time of the year’ so ‘if you are going to get it you will get it’.

It was a sad and somewhat poignant conversation to listen to. This year there has been a great deal more information provided about the need for a flu vaccination and protection this can provide. The health promoting message has been repeated for some time now. It’s never been easier to get a flu vaccination and yet there are still many people who for whatever reason have chosen not to do so. Unfortunately this group also includes health care professionals. The story about Bethany Walker, the 18 year old from Applecross in Scotland who was ‘that girl’ who died, was also linked to a story about why so many NHS staff in Scotland have not had the vaccination. As I write this blog, just some 40% of NHS staff in Scotland have been vaccinated. Back in England, and in the NHS Trust I am involved in, some 72% of staff have been given the flu vaccination. 

This year there has been a growing call for the flu vaccination to be made compulsory for all those working in health and social care settings. The outgoing NHS England’s National Medical Director, Sir Bruce Keogh, noted that ‘30% of people with the virus do not know they are carrying it, so NHS staff may not be aware they could be putting patients, colleagues and their own families at risk’. The debate over compulsory vaccination is likely to be very polarising and distracting. As far as I am aware unlike the US, here in the UK today there is no compulsory legal basis requiring people to be vaccinated against anything. Even the 1853 law requiring compulsory vaccination for small pox was discontinued in 1948. Despite a small outbreak in Glasgow in 1950, by 1978 the WHO announced that the smallpox virus had been eradicated globally.

Under the WHO Global Vaccine Action Plan, measles and rubella are targeted for elimination in 5 WHO regions by 2020. The UK achieved this in 2017. This was achieved by voluntary means with most parents embracing the need to have their children vaccinated against the potentially deadly childhood diseases of measles, mumps and rubella. The MMR vaccination was introduced in 1988. Apart from a fall in uptake in the late 1990s caused by the now discredited research by Andrew Wakefield, linking MMR to autism, voluntary vaccination uptake has been maintained at +90% levels.

At my NHS Trust, we had a 100% take up of this year’s flu vaccination by the Trust Board of Directors. Now our Medical Director was one of those getting his flu vaccination along with the rest of us, so I was surprised to hear him stand up and say he didn’t think it had worked to protect him! The occasion was at our Quality and Safety Committee, where he was giving a presentation regarding progress on our 7 Day Service (we are one of the national pilot sites). His comment referred to a bout of what he described as ‘man flu’ (a descriptor I really dislike!). This wasn’t flu as in the H3N2 ‘Aussie flu’ which affected some 170,000 people in Australia and which is beginning to spread across the UK at an exponential rate. But it was severe enough to make him feel really rough, not ill enough to go to A&E, or his GP, but ill enough to feel the need for care. Fortunately for him his wife provided for his care, in the form of keeping him warm, making sure he had plenty to drink, giving paracetamol, and making him rest. 

The word ‘fortunately’ was his word. He asked us to consider those without family support, particularly the elderly who might experience similar symptoms and have no one to provide them with care. If that care is not available to them and they pitch up at our A&E departments seeking some care, should we be at all surprised? Like many others, I believe that 7 Day Services should not just be about hospital care. However, we have a long way to go in ensuring the provision of effective integrated community based care is available to all. So for many people the hospital still provides a ‘containing nest’, which when they are poorly, is a safe place to be, even if it is not somewhere they really should, or even need to be. And if you have not had your flu vaccination yet, its not to late to do so.

Of pirates, parole and prescriptions; we are our choices

I thought a lot about the notion of choice[s] this past week. There were plenty of stories to stimulate my thinking and choose from. For example, we all had the choice of having a flu vacation and giving ourselves protection from the deadly H3N2 influenza strain. H3N2 is likely to trigger the worst UK flu season in 50 years. If you chose not to have the vacation, read this; or the story that you can now choose to have a healthy full English breakfast thanks to nitrite free bacon. The WHO warns that bacon cured with nitrites is as dangerous for our health as asbestos, and smoking – due to the carcinogenic nitrosamines produced when ingested - see here.

I also caught up on the story of Michael Afanasyey, an environmental engineer, studying at the Delft University of Technology. He claims to be a ‘priest’ for the Church of the Flying Spaghetti Monster. It’s an organisation that ridicules organised religions (you can read more about the so called Church here). Afanasyey is taking the University to the Dutch Institute of Human Rights after they refused to allow him to defend his PhD thesis wearing an outfit of his choice, a pirate’s costume. Pirates play a significant part of the satirical religion. The so called ‘believers’ claim there is an inverse correlation between the number of pirates in the world and global warming.

There was yet another story last week about global warming denier, Donald Trump and his mental health state. The origins of the story appear to have stemmed from the publication of Michael Wolff’s book ‘Fire and Fury’, an account of Trumps first year as US president. The book claims to have captured life inside the Whitehouse, and the sometimes very erratic and unpredictable behaviour of the president. His behaviour has increasingly become the focus of alarm and concern over his mental state. Current UK media commentary includes discussion around whether Trumps forthcoming medical examination will include a mental health element, and if so will this determine whether he is fit for office.  

Although there is a presidential convention that all US presidents undergo an annual medical examination, actually there is no rule or law that requires this. It will be Trumps choice to take the examination, as it will be to release all or none of the results to the public. Even then it would be incredibly difficult for the Vice-President (and the majority of the cabinet) to evoke the 25th Amendment and deem Trump physically or mentally ‘unable to discharge the powers and duties of his office’.  Deciding whether someone’s behaviour and actions are the consequence of a mental illness or not has been a long standing problem.

Way back in 1843, a man named Daniel McNaughton attempted to assassinate the then UK Prime Minister, Sir Robert Peel. He accidently killed his secretary, Edward Drummond instead. Following a lengthy criminal trial, McNaughton was acquitted of his actions because he was deemed ‘insane’ and could not be held accountable for his actions. It was an outcome that caused a great deal of public anger and concern. I imagine the anger was similar to the public anger seen following the news last week that John Worboys was to be released on parole from his prison sentence. 9 years ago he was convicted of raping 19 women, but its believed he may have raped up to 100 women. In the McNaughton case the public outcry resulted in the establishment of the so called McNaughton Rules. These were 5 questions that attempted to redefine what ‘insanity’ was. They have been used internationally in various modified forms since this time.

I hope the public outrage over the release of Worboys also results in changes in the way in which the perpetrators of rape and sexual assault are treated by the criminal justice system. Likewise, I hope that current sex offender treatment and rehabilitation programmes continue to be regularly evaluated in terms of their effectiveness. The organisation Rape Crisis (see here) remind us that approximately 85,000 women and 12,000 men are raped in England and Wales every year (approximately 11 adult rapes every hour). Nearly 500,000 adults are sexually assaulted every year, and 1 in 5 women aged 16 – 59 have experienced some form of sexual violence since the age of 16. Only 15% of those who have experienced sexual violence choose to report this to the police. It maybe that Worboy has served his sentence, and will be strictly monitored while on licence, but for his victims there will be no parole from where they find themselves after what it was he did to them.

The saddest story about choice I read last week was undoubtedly that of the inquest into the death of Megan Robertson. Megan was a normal 15 year old who liked make up, music, going out with friends, had a great sense of humour. According to her mum she could be ‘bolshie and an absolute madam - when things didn’t go her way she would slam doors like all 15 year olds’. Megan lived with frontal lobe epilepsy, which meant for her she experienced very frequent nightly epileptic seizures. She struggled with the side effects of the medication she was prescribed to manage this condition. In the weeks leading up to her death, she decided to only take 3 of the 7 doses she should have been taking. Megan had great support from her family, from a specialist nurse and a neurologist. All had spent time discussing with Megan the possible consequences of her choices and decisions about managing her condition. Further investigations into her condition were offered, which Megan chose not to take up. 

Her post-mortem revealed that Megan had an underlying (and unknown) abnormal heart condition which might have caused her death regardless of whether she had been suffering a seizure or not. Her death is very sad. Might it have been avoided? I don’t know. Some might say that aged just 15, Megan wasn’t fully competent and able to make the choices she made. I don’t know that either. As Jean-Paul Sartre said, ‘we are our choices’. I do know that as I read Megan's story my thoughts were, and remain with her family and their sad loss of a daughter, and sister.