The Angels’ Share, Yellow Cranes and A(H1N1)

Last week was a real corker! I was in Porto, Portugal to celebrate a childhood friend’s wedding, but also for a bit of a break. The wedding was yesterday. The bride and groom got there on time, but the registrar was nearly 1 hour late. That is Portugal time. However, it was brilliant to be there and see my friend Keith wed his wonderful bride Ana. The ceremony was in Portuguese (with English translations), and although a little long-winded, it was great to meet up with old friends and make new acquaintances. The wine flowed, the dancing was embarrassingly ‘dad dancing’ and the company welcoming and warm. 

Coming to Portugal from a very cold and wet England, I was hoping for some sunshine. Apart from one day where the rain fell incessantly, the other days were sunshine filled and warm. I walked around in my shorts and t-shirt which seemed to keep the local population amused. Many folk, out and about, were still wrapped up in their winter garb. Porto turned out to be a wonderful place. It was steeped in history, and the mix of the old and the new was truly eclectic. There was plenty to do and see. 

It was a case of when in Porto, drink the port. There were many Port Houses to choose from and it was the Calem that had been recommended, so that where J and I went to take the tour. Immensely interesting, the tour took you through every stage of the port’s production. What was staggering was the length of time the port was stored in vast vats and barrels before being bottled. In most instances it was stored for many years (10, 20, 30 years). The port is left to mature with hardly any interference from the wine makers. But there was talk of the ‘angels’ share’, which accounted for the gradual loss of port from the vats over the years. Nobody knew what happened to the port or what caused its disappearance, hence the name ‘angels' share’. 

The tour ended with the sampling of 3 different ports – all of which were superb. During the week I took many opportunities to refresh my memory of what that port tasted like. There were many wonderful buildings to visit – not least of which was the main railway station – Sao Bento. The main entrance hall (and this was huge) was covered in blue and white tiles, which told of Portugal’s history in pictures. We crossed some of the highest and most beautiful bridges I have ever seen, wandered up and down small cobbled streets no bigger than alleys, with tall, colourful and incredibly narrow houses. We went up in a funicular railway and down in a cable car. And apart from the old tram service (worth £2 of anyone’s money) we walked everywhere – to the pristine beaches, the riverside bars, parks and churches. The only downside was the scarcity of vegetarian restaurants or even a vegetarian option on the menu. I have never eaten so many omelettes in my life. Sometimes, twice in one day. It was like being on the set of Gavin and Stacey. 

Everywhere there was building work going on. I must admit to becoming obsessional about the many yellow tall cranes that were everywhere. Unlike in the UK, these cranes were operated by remote control. I have to say, on many occasions I stopped and stood transfixed by the way the crane operators used their remote controls to move the cranes. Not only did they do so with pinpoint accuracy, but also at speed. It was fascinating, although J couldn’t see it herself. 

What we did both find fascinating was the MIPO Museum. It is a museum dedicated to the work of the Misericordia, and looked back over the past 500 years. The Misericordia is an organisation founded on the benevolence and generosity of many philanthropists.  Whilst there was much to be seen around early health and social care services, I was interested to see what was said about mental health. I wasn’t disappointed. On March 24th 1883, using the last of a huge legacy left by the Count de Ferreira, the first ever psychiatric hospital in Portugal was built and opened. By 1900, the hospital provided inpatient care to 520 people of both sexes. There were 14 wards and patients which were ‘organised’ by mental health condition, age and social groups. It is still there today, although the quality of care provided, now reflects contemporary approaches to mental health care. They are also great believers in the use of art as a therapeutic device, something I will see for myself next Monday.

I was surprised by the look of the hospital (seen in one of the museum’s photos) which bore an uncanny resemblance to the hospital in which I undertook my nurse education and training back in 1975! Likewise, there were the usual exhibits of ‘straight jackets’ and other mechanical restraints on show. Coincidently, both the bride and the groom have a professional background in mental health care. Keith, who is 23 days younger than me, started his mental health nurse training a year after me. Unlike me (the retired me), he still works as a quality and risk consultant in health care organisations in different parts of Europe. Ana (who is a Social Worker by background) continues to work in a mental health hospital in Porto and has responsibility for the quality of the services provided.

Unfortunately, they both went down with a heavy cold in the week before their wedding. They described it as ‘flu’, but given their presence at the wedding yesterday, I strongly suspect it wasn’t. Flu can be a killer. Neither of them had had this year’s flu vaccination. This was somewhat surprising as 95% of the Portuguese population believe that the flu vaccine works and is beneficial. However, within the health professions, only 30% of the European health workforce had a flu vaccination last year. It may well be that Keith and Ana are like many of the doctors I know who refuse to have the flu jab in the totally unbelievable belief (in the context of their scientific education), that they may get the flu from the flu jab. In any event, their ‘flu’ didn’t interfere with their wedding or the celebrations and I wish them many years of happiness together.   

Talking about the difficulties of having a difficult conversation

Last week turned out to be a real emotional rollercoaster of a week, with many ups and downs. I think over all, the ups had it. But the downs were hard to work through. What caused these ups and down? It was handing over the keys from the Old House to the new owners. We had lived in the Old House for over 20 years and its walls contained many memories. Some were good; others not so, but overall it had been a happy home for much of that time. The New House is in the coastal town of Bispham, situated on the Fylde coast. It shares the coast line with eccentric Cleveleys; entertaining Blackpool and; expensive Lytham. I get to pick up the keys to the New House in 12 days’ time and I am so looking forward to living near the sea again.  

When it came to handing over the keys to the Old House to the estate agent, I had to wait a few minutes and the estate agent asked me how I was feeling. I was very surprised to find my eyes were leaking and it was a difficult conversation. It wasn’t the only difficult conversation I had last week. 

Conversations of any kind are a funny thing. It is surprisingly hard to find a definition of what a conversation is other than usually a conversation involves at least two people talking to each other. Mary Conklin, a writer on social etiquette, had this to say about conversations way back in 1738 - ‘they are the polite give and take of subjects thought by people talking with each other for company’. This is a definition that might still hold true today. Certainly, conversations like all social interactions, tend to follow an established set of ‘rules’. If these are not adhered to by one or other of the parties to a conversation, then it usually deteriorates or ends. 

  

I hate it when people cut across me in conversation. The result is that I simply stop talking. Likewise, I’m amazed at the number of people who, in conversation with me, know what I’m thinking, and feel so confident in their mind-reading abilities that they tell me. In such situations, the result is that I simply stop talking. Conversation will involve a great deal more nuanced and implied context than simply the words being spoken. I have always told my students, that in conversation with their patients, they need to learn to listen to what is being said, and equally what is not being said.  

Many folk working in health and social care will be familiar with difficult conversations. This might involve telling someone bad news about their prognosis, finding the words of comfort for someone dying, or challenging someone’s bad practice, particularly if they are a senior professional. Those involved in mentoring students will know how difficult some conversations can be. Perhaps bringing to the student’s attention something that needs to change, or the fact that they haven’t achieved their placement learning objectives. 

As a Dean of School, I've had my fair share of difficult conversations too - for example, telling someone they haven’t got the promotion they wanted, or they have not passed their PhD examination. And there were those difficult conversations where a colleague comes to tell me they have received a diagnosis of a life-shortening condition. One of the first things I did on my appointment was to get rid of the board room type table, replacing it with a low coffee table and armchair seats. I would tell people that I could only help them if they put the problem, or issues on the table. But it doesn’t matter how many times one has been involved in a difficult conversation, in my experience they are always difficult. However, what experience does help with, is the knowledge that the other party to a difficult conversation is also likely to be as apprehensive as you. 

So last week I had yet another difficult conversation to deal with. It was a conversation that was required to be had to try and resolve an apparent breakdown in trust and a dysfunctional working relationship between some very senior managers in an NHS Trust. I had done my preparation and had practised the questions I wanted to ask, how I might frame those and the order in which I might want to ask them. My mindset what was not a combative one. There was no intention on my part to end up a winner, with the other person being a loser. I wanted to set out my stall, both how I saw my responsibilities as the Senior Independent Non-Executive Director, and what I thought had brought us to the meeting. 

It was then over to the other person to tell me how they saw the situation and the issues involved. Thankfully it was then possible to agree what was fact and what was perception, and importantly consider the impact the situation was having on them and the team in which they worked. In an organisation that sometimes complains that leaders are not visible, I was acutely aware that the rumour mill was a powerful entity and others might already be aware of the apparent breakdown. Anyway, it was possible to develop some possible ways forward, I wouldn’t say we were able to resolve all the problems, but we were able to agree the next steps for each of us. In a week already heavily charged with emotions, I was pleased that we were able to get to the place we did. 

Finally, in thinking about this blog, I came across a study undertaken in 2007 that completely dismissed the popular notion that women use more words in their conversations than men. Actually, the study showed that both men and women use about the same. On average we use about 16,000 words per day. I’ve used mine up already, so I will stop talking now.      

Education, experience and knowing when to reach out to others

Well last week was one that was jam packed with different experiences. There was a Remuneration Committee meeting, where among other things I learnt much about the incomprehensibility of the NHS ‘Very Senior Managers’ pay guidance, and the possible introduction of a ‘portfolio salary’ approach in the future – yes I can feel your envy at the sheer excitement of my life. I hired the largest van I have ever driven and took the last load of furniture up to Scotland and drove back in the fog. Whilst I was packing yet another box, I came across a photo album (younger readers ask your parents what this is). It was a photographic record of my first trip to New York, nearly 25 years ago now. The Twin Towers still stood, and my body still looked good too! 

I had another one of those ‘Hello, are you Tony?’ experiences, where someone you don’t know, but who knows of you, comes up and introduces themselves. Something I find very strange these days (but that’s the subject for a different blog). In this case it was a young man, who unbeknown to me, was the son of J’s brother. He was working in the van hire shop. He had seen my name on the computer and recognised it, and just wanted to say hello! And then there was the cooker repair man experience. I watched in amazement as he removed what looked like 100s of screws to get inside the oven and replace a broken element. I was fascinated to see them all being put back in again, the oven switched on and normal cooking service resumed. Brilliant! 

However, last Friday evening’s experience was a very painful one. Like every week for the last 10 weeks, I had spent the previous two days moving very heavy objects, loading and unloading these into vans as part of a complicated series of house moves. The result has been the onset of lateral epicondylitis (or Tennis Elbow to you and me). If you have ever experienced this, you will know just how painful and debilitating the condition can be. But it wasn’t this that caused the pain. It was the sad news that following a very short illness, Dianne Oxberry had died aged just 51 years old. Possibly for many folk living outside the North West of England, they may not have heard of Dianne even though she had many roles on TV over the years. She was a weather presenter extraordinaire on our local BBC news programme North West Tonight (@BBCNWT). Famous for her fabulous high heels, razor sharp wit and championing the equal rights of women. Like many others, my thoughts are with her husband and her two young children at this very sad time.

What made the evening painful and very poignant was the way her colleagues delivered the @BBCNWT programme. There was a great deal of raw emotion on display and many of her long-term colleagues and friends joined the programme to pay their tributes. It was both hard to watch and difficult to deal with the suddenness of the news. There was no weather report presented that night. I was struck by the outpourings of love for Dianne, both from those in the studio and those sending in messages via social media. She will be missed by many. 

One of those in the studio talked of having sat with Dianne early in the week as she lay in the Christie Hospital. He told of how he held her hand as she drifted in and out of consciousness. I’m sure it will have brought her great comfort. It also made me think about those who in similar situations who don’t have friends and family around them at such a time. I was going to write ‘except with just nurses to care for them as they pass from this life’ – but I changed my mind. 

Let me explain. Last week the University of Salford ‘graduated’ its first cohort of Trainee Nursing Associates. They were a great bunch, all ages and from all walks of life. There were many senior nurses and managers from the local health economy there to share in the celebrations.  Now the introduction of these new entrants to the health and social care workforce has not been greeted with universal approval. There are many qualified nurses who see the Nursing Associate as some kind of threat to the profession. I’m not so sure. They will be regulated by the NMC and have a very different curriculum underpinning their education and training to that of qualified nurses. Their scope of practice obviously reflects this difference in education. At the celebration last week, they were described as a group that will take on some of the practical tasks of qualified nurses freeing them up to take on some of the more complex tasks. In the context of Dianne’s death, I wondered about this notion of complexity. I thought about the man who held Dianne’s hand as she slowly left this world. Is holding someone’s hand in such a situation a complex task? No, but perhaps knowing when to reach out and do so requires a different mindset. Maybe that comes with experience alongside education and training. 

Coincidentally, last week the BBC in Northern Ireland reported on the fact that older students studying to become qualified nurses bring an all-important ‘life experience’ to the nursing profession. Student nurses in Northern Ireland still get a bursary. A third of students at the prestigious Russell Group UK Queen’s University in Belfast have started their nurse education ‘a little later in life’. It was the same situation in England before the bursary was scrapped. However, in England, Trainee Nursing Associates get paid at Band 3 of the National Agenda for Change pay scale. Time will tell if these new entrants to the traditional workforce really do support the existing professions. I do know that whoever it is, when the time comes, I want someone there to reach out and hold my hand, if just for a moment.