Cure sometimes, treat often, comfort always

Some 34 years ago, I moved to Manchester to start a new job as a commissioning nurse for the North West Regional Forensic Adolescent Service (Gardener Unit). It was the only NHS funded and managed forensic mental health service for young people. This service was based in a purpose built secure unit on what was once known as Prestwich Hospital. Prestwich Hospital was built as an asylum (in the true sense of the word) way back in 1851. By 1900, it had grown into the largest mental health hospital in Europe. 84 years later when I arrived, it was a much smaller hospital, largely made up of very specialised mental health services. These days it provides acute and community-based mental health services to many parts of Greater Manchester, the North West and beyond. 

The Gardener Unit was a relatively small medium secure unit. The latest data (2015) reveals that in England, there were 1,450 young people in secure settings at any one time. Over 300 of these young people were in secure mental health settings, the rest in what is termed welfare secure settings. However all these young people have clearly established (and often significant) mental health needs. Those young people in secure in-patient mental health units such as the Gardener Unit will present with the highest risk of harm to others. Typically these are young people who have committed a serious or grave crime. They are often vulnerable, have challenging behaviours, and self-harm. Secure settings such as the Gardener Unit have both high levels of physical security as well as high levels of procedural and relational security.  

My time there was a truly wonderful period in my career as a nurse, service manager and ultimately an academic. I worked there for 10 years before taking up my first University job at Manchester Metropolitan University, moving to the University of Salford 10 years later. Last week I was reminded of my time at Prestwich. I read the background to the public inquiry which began last week, into the contaminated blood scandal that affected many thousands of people. It is estimated that some 3000 people have died as a direct consequence of being given contaminated blood products.  Thousands of patients were given blood products infected with hepatitis and HIV during the 1970s and 1980s. One of these people was one of the first patients admitted to Gardener Unit. They were someone who had been given a contaminated blood product (Factor VIII) as part of their treatment for haemophilia. As a consequence of this they had developed HIV.

Back in 1984, little was known about HIV and AIDs. There was a societal climate of fear, discrimination and stigma associated with HIV and AIDs. This was mirrored in part by those staff working in the Gardener Unit. We were ignorant and sometimes this showed in our approaches to this young person. We simply didn’t know enough about the disease to use science and evidence-based knowledge in dispelling the myths and misunderstandings. Whilst this young person had committed a grave crime, the fact remained that they were simply an innocent victim, bewildered, and vulnerable. It didn’t help that their family, friends and home town was some 300 miles away from Manchester.

Fast forward to 2018, and we know a lot more about the prevention, and treatment of HIV and AIDs. The blood product risk has been eliminated and the greatest risk of contracting HIV today is through sexual relationships. NHS England, currently has a trial of the preventative medication PREP, (perhaps ironically, a pill with a similar shade of blue to Viagra). PREP is a pre-exposure prophylaxis, and is a daily pill that disables HIV before it can gain a stranglehold in the body. The pill is being made available to those at risk of contracting HIV, in the main young gay men. Trials suggest that it can cut the risk of becoming infected by up to 86%. Before the trial began, people buying the drug privately have been linked to the first ever fall in new infection rates in gay men.

However, there is no room for complacency. Here in Great Manchester, there are more than 5,000 people living with the disease (three times the national average). There are still some 300 new cases of HIV every year. The Greater Manchester Mayor, Andy Burnham has recently committed £1.3m to help stop the spread of HIV in the region. The city is set to join a growing global network of cities working together to stop the spread of the virus. It is a commitment only made possible through the devolution of funding and responsibility for managing the health and social care services to the region. 

I have often wondered what happened to all those young people who were the early patients at the Gardener Unit. I do know that working with troubled young people was as much a privilege as it was at times a challenge. I do also know that for me, working with such young people brought to life the words of Hippocrates ‘cure sometimes, treat often, comfort always’. 

Promoting mental health as a place of possibility and promise in the sunshine of Croatia

Well what a week! Tuesday I was up at 4.30am to drive to the airport en route to Croatia. I normally use a ‘meet and greet’ service to park my car. However, J had secured a deal on Groupon which reduced the cost of parking a car at the airport. Now then sometimes getting a cheap deal is not always the best deal. I had to ring the firm up when I was 20 minutes away from the airport (difficult to do on a motorway even with a hands free phone). Sure enough there was a man waiting for me at the drop off point, who asked for the car keys and before I knew it, had driven off with my car. I have only had it for six weeks, so I was a little perturbed. I had been told to go to level three on my return and I wondered if I would ever see the car again. However, when I came back and got to level three, after a wait of 45 minutes, my car appeared. It seemed to be undamaged, but perhaps somewhat sadly there was no apology for the delay in returning it to me.  

I was in Croatia to present a couple of papers with my friend and long term collaborator Professor Sue McAndrew. This was the 7^th European Conference of Mental Health. We have been to all but one of the conferences. Up until this conference, it was Tallinn, Estonia that had been my favourite venue. Split, Croatia, was something else. The city is wrapped around the coast and is nestled under huge, imposing mountains. The old town was medieval, beautifully preserved and full of tiny narrow winding streets. There are pavement cafes at every turn, and fish of all sorts appeared to feature heavily. The streets were thronged with folk, day and night. Everyone appeared to be making the most of the fabulously hot weather. We joined in and explored the city, and the coast (although it was burning hot when out in the sun) before the conference programme got started. 

The conference programme was full on, with some cracking keynote speakers at the start of each session. These featured talks on human rights and mental health; violence prediction; pragmatic psychology (my favourite); and the co-production of mental health policy. The concurrent sessions were also fabulous. There was a mixture of papers presented by academics, practitioners and service users.  I enjoyed hearing of the use of dogs in therapeutic work with children and young people; the very difficult job of working on a small island in the Caribbean (there is a vacancy for one more nurse:- DM me if you want details); how to balance the impact on sexual function and sexual desire with the benefits of prescribing psychotropic medication; and the use of ‘serious games’ and gaming in facilitating nurse education. 

Sue and I had two papers to present. The first one, which was presented in the first session on the first day, was a paper that had been co-produced with one of our PhD students, Dr Gareth Lyons. Unfortunately, despite trying hard we could not secure the funding for Gareth to join us in Split, so we presented his work on his behalf. His PhD study had focused on men with eating disorders and the way they can get lost in services which usually cater almost exclusively for women. It’s estimated that 1.25 million people in the UK live with an eating disorder. Whilst it’s true that many more women than men have an eating disorder, between ten and 25% of all those with an eating disorder are believed to be men. Gareth’s work was well received. We have sent a joint authored paper off for publication, watch this space. 

Our second paper was a ‘work in progress’ paper that considered the relationship between ‘doing therapy and doing research’. Mental health nurses in particular have the skills to do both although this is not something always appreciated and accepted. Sue and I have been interested in identifying what these skills are, but have also been interested in why people either want to participate in research or undertake research. We based our conference paper on some 26 PhD students we have supervised over the years. Drawing upon an auto-ethnographic approach we reviewed and analysed our supervision records and notes. Four emergent themes came to the fore. These were: Doing research ‘on’ or ‘with’ participants - the ethics of a symbiotic encounter; I’m just a researcher who can’t say no – the tensions in being a nurse with professional obligations and being a researcher; Transfer of feelings – developing both a sensitivity towards others and using this appropriately in recognising the presence of transference and counter transference present in all relationship encounters; Having no control, not being responsible – so is research as therapy so wrong? 

These were questions we explored in our paper. The audience were kind, but equally they challenged us. Together we explored the similarities of being a nurse and being a researcher, or being both. There lies a paper waiting to be written. In a week that began by saying goodbye to Neil, my friend, colleague and fellow NED at his funeral, a funeral celebrating his life, (and Christopher, you are not forgotten either) it was great to meet so many other old friends. The conference goes from strength to strength – next year we are in Belfast, and whilst the weather is unlikely to be as good as Split, it’s reassuring to know that there will be many good folk there all #makingadifference to the lives of others. 

Hip, hip hooray for the NHS

I am a great believer in serendipity. When thinking about this week’s blog, I found myself ‘stuck’ on the news of the appointment of Lord David Prior as the Chair designate for the NHS England. I say ‘stuck’, as I wanted to say something about my dismay at his appointment and what I thought it might mean for the NHS, but also pulled away from developing such a narrative, as I try to avoid political commentary in my blogs. Lord Prior is well known in the NHS. He was the former Chair of the Care Quality Commission (CQC) before stepping down to take up the role of Under Secretary of State for Health in the previous Conservative government. He has held Chair positions at a couple of NHS trusts, and currently remains Chair of University College London Hospital (UCLH) NHS Trust. 

I found it interesting that, despite what I thought was the hospital’s and associated medical school’s well-deserved international reputation, the UCLH was only given a ‘Good‘ rating by the CQC at its last assessment. More interestingly still (at least for me as a researcher and academic) was that UCLH was only ranked 40^th in the UK and 607^th in the world by the Ranking Web of World Hospitals*, whereas Wrightington,Wigan and Leigh (WWL) NHS Trust, where I sit as a Non-Executive Director (NED), is ranked 27^th in the UK and 503^th in the world (*other ranking organisations are available). 

It’s at WWL where last week’s serendipitous experience happened. I was sitting in the car park waiting to go into a meeting and as I was early, I decided to start to write up my blog notes on the inappropriateness of Lord Prior’s appointment - the original focus for this week’s blog. I noted that he had made a number of controversial comments on the NHS and healthcare during his career – including that… continuing to fund the NHS through taxes ‘must be questioned’ and that ‘even God would struggle to manage the NHS due to its size‘. I am not sure of the degree of independence he can bring to the role and it certainly looks like his appointment is another example of the creeping politicisation of the NHS.

Although my heart wasn’t in it, I promised myself I would return to the notes in due course, and closed my laptop and went to meet my colleagues. I was at Wrightington Hospital, part of the WWL family, and a hospital with an international reputation for orthopaedics. I was there to undertake a Leadership Safety Walkabout. These are regular events in our hospital calendar and an opportunity for Executive, Non-Executive Directors and Governors to visit clinical areas and meet the colleagues working there. This visit was to the theatre suites. After meeting my other walkabout colleagues, I was asked to change into surgical scrubs – which sadly for me (as I always wear black) only came in a fetching duck egg blue. 

We were taken on a ‘patient journey’, which as well as being a great way of gaining an understanding of how the theatres operated (sorry), also provided our hosts with the opportunity to give us a brilliant history lesson on how services at Wrightington have developed. The person most associated with this history is the late Sir John Charnley. In 1958, he pioneered the first hip replacement operation. This is now one of the most common operations undertaken globally. The first recorded attempt at hip replacement was carried out in Germany in 1891 (a crude operation that used nickel screws, Plaster of Paris and glue). The first metallic hip replacement surgery was undertaken in the US. However, it was Charnley’s dedication to research, science, and collaboration with biomechanics, which had the biggest influence on contemporary orthopaedics. 

He created the Wrightington Centre for Hip Surgery, and has educated generations of orthopaedic surgeons through his textbook on conservative fracture treatment. In the early days, he persuaded 99% of his patients to let him have the ‘hips’ back when they died. These he tested for wear and tear and this information allowed him to refine the design of his implants and approaches to fixing them. This research and development meant that by 1970, Charnley’s design almost completely replaced all other designs.

His presence is still very tangible within the theatres. He created an isolation zone within which to operate – this is now replaced by a similar sterile zone enabled through pressurised air. Everyone I met during the walkabout held his work in great regard. There was great pride in the work they do, and in the sense of belonging they all shared. At the group discussion in the coffee lounge, the conversation was wide-ranging. What stood out was the shared consensus that the NHS was still the best way to provide specialist health care, and the NHS was better kept as a public service – Lord Prior take note! Getting back to my car I deleted the notes I had previously made and knew then what I wanted to write about in this week’s blog…

Ps – this week’s blog is dedicated to my friend, colleague and fellow NED, Neil Campbell, who very sadly and suddenly died last weekend. His contribution to health and social care has been phenomenal, both in Scotland and here in Greater Manchester. He will be greatly missed and my thoughts are with his family at this sad time.