No Such thing as a free meal – thinking about the future funding of the NHS

Last Friday, the only commitment to be found in my diary was a breakfast meeting with a colleague in Manchester. The meeting was a very good one, the breakfast, however, a slightly strange one. I ordered the vegetarian option, thinking Linda McCartney sausages, eggs, mushrooms, tomatoes and so on. What I got was very different! Two small slices of artisan bread, one smothered in tomato hummus, the other covered in something called squashed avocado, two poached eggs, a grilled mushroom, and three spinach leaves. When the bill came It was clear that I needed to take out a mortgage to pay for it. Fortunately my colleague and friend picked up the bill, although he did say it was because I’m a pensioner now! Thank you Brian.

It was an experience that I imagine Shahid Khan doesn’t have very often.  Forbes estimated that Khan’s net worth, some $8.7 billion, ranked him 158th in the world in 2017. Khan is a Pakistani-American billionaire who made his fortune from designing and selling car bumpers. He was in the news last week because of his offer to buy Wembley Stadium for £900 million. If the deal goes through, the Football Association are said to want to use the money to revitalise the grass roots game and provide hundreds of new 3 and 4G pitches. I don’t follow football at all and have never had any interest in it whatsoever. I guess the new Wembley Stadium has lost some of its iconic standing so selling it not likely to hurt the UK psyche. 

What I was surprised about was the contrast between this story and another one last week about so called ‘payday loans’.  Some 300,000 people a month take out one of these high cost, short term loans. At the start of 2017, 1.6 million people had a payday loan debt, with one in eight of these people in arrears with their payments. NHS staff, council officials and gig economy workers are among the most regular applicants for such loans. Indeed, NHS workers applied for more loans than any other workers in London, Cardiff and Bristol and applied for more loans nationally than any other organisation’s employees. It is a story that matches those last year about nurses having to use foodbanks. 

Perhaps the recent pay rise announced at the end of March this year will go some way to redressing this situation. The new pay deal, which hasn’t yet been accepted would see pay rises between 6% - 29% for all staff except doctors, dentists and very senior managers. Those on the lowest pay scales will benefit the most. If accepted the pay rises will be phased in over the next three years. Once inflation is included, the pay rises, whilst being most welcome, will probably only keep pace with the projected inflation rate over the next three years.

I am not sure how that will help recruitment and retention in some parts of England. For example, around 30,000 nurses leave the NHS each year. The Royal College of Nursing estimates that 40% of these nurses are considering leaving London over the next five years as a consequence of the very high housing costs in the capital. Sir Robert Naylor’s report, NHS Property and Estates: why the estate matters for patients, published in the Spring of 2017 recognised that the NHS estate was vast, but not always well utilised. It costs well over £8 billion each year to run, and a further £2.3 billion to maintain and improve the wider estate and infrastructure. 

There are clear advantages to the wider NHS of thinking differently about how the NHS estate is better utilised. So I was interested to read last week of the work and ideas of a company called ZEDpods (see here ). They have come up with a really innovative idea to tackle the issue of how to build and install high quality, low carbon homes for key workers and those trying to get on the property ladder for the first time. Thinking laterally, ZEDpods have thought about using the ‘air rights’ to build affordable housing above carparks. For land locked NHS Trusts such as the one I’m associated with, being able to build affordable housing above the car parks we have without losing the use of the carparks must be a win/win solution.   

Additionally, the ZEDpod concept would allow for the development of more ‘step down’ beds – thus helping to reduce the estimated 2.3 million delayed bed days each year. Such a provision would be great for those patients who are medically fit for discharge and have no clinical need to remain in hospital, but have nowhere else suitable to go. Given that Lord Darzi predicts that the NHS needs £50 billion more resources by 2030, anything that can contribute to meeting this need must be welcome. And Shahid Khan, if you want to contribute, feel free. 

A good story, told well, can help others to listen and learn

One of the skills I admire in others is their ability to tell a good story. I don’t mean that the story has to be a happy or funny story, stories can also be poignant, sad and difficult to hear. A story told well can be inspiring and motivating, and as in the case of reading to my grandchildren, an exciting way to for them to explore the world. Equally, I love listening to their stories, tales that reflect their growing awareness of the world, and also that creative imagination young children have. 

As a nurse I have listened to many patient stories and stories from their families and friends. I taught my students the importance of listening to what was being said and also to what wasn’t being said. Both can be equally powerful. As a nurse researcher I have listened to stories of abuse, of mental health problems and the challenges of everyday life and the negative impact these can have on a person’s health and wellbeing. 

Stories can be told in many ways. Verbally, through pictures and films and of course through writing. I write stores myself, in the form of a weekly blog. This is something I have done for many years now, and the blogs are often constructed around stories of my own experience or reflections on life. I don’t think I’m a particularly good story teller, so I am always surprised when people, (other than my Mum and Dad) read them the blogs and take time to respond.

So whilst stories can be amusing or sad and a part of our everyday communication, stories can be powerful too. I sit as a Non Executive Director on the Board of an Acute NHS Trust. As someone with a nursing background I consider it a great privilege, and an opportunity I cherish. Every Trust Board start off with a patient or carers story being told. Over the last 2 years these stories have been communicated using videos. There are stories from patients who have enjoyed great experiences of care, and others where the experience has not been so good. However, there are always lessons to be learnt, not just by those sitting at the Boardroom table, but are stories shared across the wider Trust community. The videos have become a brilliant learning tool. They help people reflect on what they have heard, help people challenge and bring about change. 

At yesterday’s Board meeting we heard the story of someone profoundly deaf and her experience of care. It hadn’t always been good. She had decided to do something about it and had met with the Chief Executive and Director of Nursing to express her views and share the story of her experience. The video told the story of what she had gained in response; why it was important to have high quality interpreter services available for the deaf community; and how she was going to help the Trust better meet the needs of this community. 

It was a good story with what I think will be a great ending. If it feels right, why not share your story, and maybe even write a blog for #ExpOfCare 

Health creation: the lost art of ‘comprehensibility, meaningfulness and manageability’

Last week saw me get back into a rhythm of reading and reflections, something I missed out on the week before. So I had a backlog of different reports, articles and papers to read. One of which was the report from those good folk at the Health Foundation: What makes us healthy? An introduction to the social determinants of health. The Health Foundation is an independent charity that aims to create the achievement of better health and better health care for those living in the UK. They believe good health and health care is key to a flourishing society. The report is a great read. In the past I have confidently stood up in the classroom and delivered a lecture on what might be meant by social determinants of health. I wish that I had this report to hand when I did so. Its entire 62 pages are crammed full of facts, statistics, case studies that made for compelling reading. 

The report describes the factors which in the daily lives of people are factors that can create and support health and wellbeing. This is an approach to health that draws on the work of the medical sociologist Aaron Antonovsky. He took a very different approach to public health research, and for the last 25 years of his life he developed what he called ‘salutogenic’ questions as to what creates health (salutogenesis) rather than look for the causes of disease (pathogenesis). Antonovsky believed in real life research, undertaking this with individuals, communities, populations as well as health and care systems. He was interested in understanding people’s ability to assess and understand the situation they were in; what might motivate them to move in a health promoting direction; and whether they had the capacity to do so. He called this continuum ‘comprehensibility, meaningfulness and manageability’.  

Of course it’s more complex than that. Sir Michael Marmot, Professor of Epidemiology and Public Health at UCL, noted that the conditions to which we are exposed influence our behaviour. Whilst most of us cherish the notion of free choice, our choices are constrained by the conditions in which we are born, grow, live, work and age. In the UK, 1 in 5 people live in poverty, and over 50% of these people live in working households. This statistic is even sadder when one considers that this is happening some 76 years after William Beveridge published his report on the welfare state. His report set out a number of recommendations for tackling unemployment, child care costs, improvements in the provision of good housing and the promotion of public health. It was a report that eventually led to the creation of the NHS.  

In a world where it possible to create bio-artificial ‘hearts in a jar’, we appear to have lost our way a bit when it comes down to looking after ourselves, our families and the wider population. Professor Ronald Li, working for a company called Novoheart are using stem cells to create the ‘heart in the jar’. They need just 2.5 ml of blood to do so. They create stem cells that can be turned into a miniature ‘clone’ of your heart which not only beats like yours does but will react to new drugs in the way that your heart would. The implications for developing new drugs way before they get to human trial stage are many. Developing new medicines is lengthy expensive and a very inefficient process. Typically it can cost £1.2 – £1.80 billion and take 10 years to develop a single new drug. 

Likewise biotech companies are ‘printing’ living tissues using specialised 3D printers. Such tissue could be used to produce skin grafts or cartilage for joints. Scientists at Arizona State University and the Chinese Academy of Sciences, recently programmed ‘nanobots’ (tiny bio-machines that can be sent into an individual’s blood stream) to shrink tumours by cutting off their blood supply. Although only tested on mice so far, human trials can’t be far behind.  The rise of nano-medicine is here to stay.

The ‘heart in the jar’ and other such developments, whilst solving many existing and emerging problems, may actually be contributing to the move away from self-resilience and the adoption of healthy behaviours and choices, towards a type of ‘hedonistic obsolescence’. And in the UK where a baby girl born in Richmond upon Thames is expected to live 17.8 more years in good health than a baby girl born in Manchester, there is still a real need to get back to basics when thinking about what might keep us healthy and able to enjoy a long, productive and fulfilling life