Knowing me, knowing you, Aha: some memories quietly remembered

My thanks to Ian Gould whose Saturday morning tweet brought back wonderful memories of the Coast to Coast walk I did some 14 years ago. It’s funny how and what can trigger a memory. Here’s another example. Last week I was reading about England’s only NHS Youth Gender Clinic and their work on helping children and young people with gender identity issues through the use of so-called ‘puberty blockers’. Children as young as 11 years of age are being offered these hormone-blocking drugs. Now I have very limited knowledge about gender identity issues, but 11 years old does feel relatively early for a child to be questioning their gender. However, similar clinics across the world are apparently now providing these drugs to young people. As with any drug there are risks. In this case there are potential adverse effects on bone strength, the development of sexual organs, body shape and or final height. The report I read also detailed the outcome of a BBC Newsnight programme that suggested another side effect was a high risk of self-harm and suicide. 

The Health Research Authority, which overseas medical studies, ensuring that they are ethical and well designed, is evaluating this programme and the risks involved. Time will tell as to what the risks versus benefits of such an intervention might be. The Youth Gender Clinic is in the very famous Tavistock clinic, now part of the Tavistock and Portman NHS Trust in London. It was in thinking about the Tavistock that sparked off a whole series of other wonderful memories for me.

The Tavistock Clinic was founded in 1920 by the brilliant therapist, Dr Hugh Crichton-Miller. It was a clinic that set out to offer an alternative to the traditional asylum-based psychiatry. Critchton-Miller was also medically trained and combined this knowledge with psychoanalytical approaches to help those experiencing Post Traumatic Stress Disorder (PTSD) after the Great War, as well as ordinary folk with mental health problems. Their sister clinic, the Portman Clinic, opened a little later in 1931. Both attracted some real leaders from the field of psychotherapy and psychoanalysis, including Sigmund Freud, Carl Jung, John Bowlby and Michael Balint. The work of these folk is still very influential in contemporary health care. Both clinics joined forces in 1994 and these days are seen as pioneers in the field of alternative psychologies. One of the most influential contributors to the early work of the Tavistock Clinic was Wilfred Bion who, along with fellow psychoanalyst John Rickman, developed the pioneering concept of a therapeutic community. 

This idea was adopted by those working in the Tavistock and it changed the way the Clinic operated and was managed. Senior posts were elected by staff, and clinical responsibility was shared, rather than being the sole responsibility of the psychiatrist. Training and learning were facilitated through exploration of real-life situations and cases often presented in the form of peer seminars. Since that time research and education have become an essential part of the work of the Tavistock and Portman Trust. Both through publications and teaching, they have become internationally renowned for their psychoanalytical and psychotherapeutic educational and training programmes. 

I came across the Tavistock Clinic very early on in my career. In fact it was I when I was much younger, infinitely more impressionable and undertaking my nurse education, I worked for a time on a newly-opened medium secure unit in Swansea. It was an era where male student nurses were issued with grey suits which you were expected to wear to work, with white coats to be worn while on duty and where shirt and ties were de rigueur. Despite there being some very troubled folk nursed on the unit, it was a very safe and peaceful place for most of the time. As student nurses we were mentored by one of two Charge Nurses, one of whom smoked a pipe for much of his shift. I have fond memories of my time there and learnt a great deal about engagement and interpersonal relationships, something I only realised was the case much later on in my career. 

There was a Staff Nurse working on the unit who amazingly managed to get a paid 12 months’ secondment to the Tavistock. Nobody knew why he would want to do so, but off he went. A year later he returned. I happeed to be back on te unit and can remember his first shift back. On to the ward he walked, blue shoes, no socks. Black jeans, open-necked shirt and no tie. If he still had his white coats they were nowhere to be seen. His authentic self had risen to the surface. Sadly, his life was made very difficult and after a few months he moved to a local psychotherapy unit in the city. His authenticity left a lasting impression on me, but again, it was only later on in my life where I realised the liberating and empowering impact of staying authentic.

Much later in my career, I had the privilege of managing the North West Regional Specialist Mental Health Services, one of which was The Red House. The Red House is a psychotherapy service, which at the time was located in a wonderful old Victorian house and run as a therapeutic community. It was a very interesting place to manage, particularly when it came to such activities as business planning, cost improvement planning and so on. Usually discussion around these activities involved meeting with the whole community, (staff and patents), often involving a Jacob’s Feast meal. I learnt a lot about managing time (the analytic hour) and the value of silence as a communication tool. Somewhat ironically perhaps, this latter lesson was surprising, as like the Tavistock clinic, the Red House was absolutely committed to ensuring that ‘talking’ therapies were available to all. So thank you Ian for sparking off what for me has been a very pleasant trip down my memory lane.

What price enlightened leadership and excellent management?

Apart from the coverage of the first man to set foot on the moon, brilliantly celebrated by the many TV programmes during the past week, there have been other news headlines of equally hard to believe occurrences. There was Freckles, the 3m manta ray who approached divers to remove fishing hooks embedded in its eyelids; the most played song on UK radio and TV was Snow Patrol’s ‘Chasing Cars’; Alexa is set to replace your GP; the Guinness Book of Records declared that Ffordd Pen Llech, in North Wales to be the steepest street in the world; and that former directors of NHS Improvement (NHSI) and NHS England (NHSE) received exit pay-outs of £300,000 each as the two organisations came together to form a new regulatory body in April this year. 

NHSI additionally reported that they had made four other exit pay-outs worth over £100,000 each, with NHSE admitting to 32 pay-outs worth more than £100,000. The total cost of exit payments at NHSI/E totalled around £10 million in 2018/19. The cynic in me notes that the long-awaited (since 2015) Government consultation on limiting public service exit pay-outs to £95,000 has just closed. Now don’t get me wrong, I’m sure these pay-outs were all in line with the individuals’ contracts of employment. However, to be reading about them in the week that NHSI/E announced the start of their third phase of restructuring the merged organisation was not good. It is a phase that will impact on nearly 1,000 members of staff, none of whom I imagine will receive anywhere near such a good exit pay-out as those above. 

I have been on both sides of the table and usually it is not a great experience for anyone. The one exception that I was personally involved in was a cost reduction programme at the University many years ago. It was euphemistically called ‘Transformation’ and was a programme aimed at creating some ‘headroom’ for investment and change. The ‘transformation’ was to reduce the headcount of academics and centralise all the administrative processes by taking them out of the individual Schools. I was responsible for achieving the headcount reduction in my School. Now many of the academics who worked in the School were people who had come into academia in later life after a long career in the NHS. So, these folk had great NHS pensions to look forward to PLUS a hefty exit pay-out agreed by the University. This happy state of affairs meant I had a queue of interested colleagues that went from my office all the way around the building and out the front door. Many of them were due to receive six figure lump sums. It wasn’t without a little glee that I presented the names to my bosses, who couldn’t do much except shout and rave and then acquiesce – it was after all their master plan. 

And therein lies the rub. As Dean of School and usually a good corporate player, I was not on this occasion committed to the programme, on the basis that I didn’t understand why we were doing it. It wasn’t that I was against change and certainly didn’t belong to the ‘if it ain’t broke, don’t change it’ school of management, I just didn’t understand the rationale for doing what we were doing. I wasn’t the only one; overall, it was a very destructive process. Like the NHSI/E programme, many people had to re-apply for a job similar to the one they had been doing or face redundancy. The outcomes were in the main negative and left a legacy of a poor organisational culture with a heavily demotivated workforce that the University had to contend with for many years afterwards. Ironically, the programme’s chief architect left the University a couple of years later, and left under a cloud, although it’s believed he too received a hefty exit pay-out.

Like the rationale used in the University transformation programme, the NHSI/E changes appear to be predicated on once more engaging with the ‘centralisation versus decentralisation’ tug of war. The current system, put in place by Andrew Lansley, viewed centralisation and lean organisational forms as a good thing, whereas the NHSI/E merger and the [re]creation of Regional Offices is about decentralisation and ensuring decision-making is closer to those delivering the services. Have a look at what is espoused in the consultation document:  “This model will be adaptive, changing over time to adjust to developments in the health system environment. For example, as local systems improve and transform, the balance of activities that take place in the regions and in the local health system may shift to ensure that services, support, regulation and improvement are all located where they best deliver improved care and health for patients.” As a piece of rhetoric, it is hard to argue with. It’s what we would all like to see happen. Likewise, the document also goes on to say: “At its heart, our new operating model will be built on the development of a new shared culture, set of values, behaviours and capabilities to support compassionate system leadership throughout the NHS”.

I guess there will always be some folk who will forever view the new NHSI/E as being made up of millennial apparatchiks pouring bureaucratic sand into the engine of the operational NHS. However, and in fairness, having personally met the new Regional Office Director for the North on three occasions recently, I do think it might be possible to turn this rhetoric into an effective reality. That said, it will need both enlightened leadership and excellent management to achieve this. And that comes at a cost. Whilst the UK media might focus on the number of nurses and doctors ‘missing’ from our NHS, equally there is a paucity of effective managers. Like hens’ teeth, good managers can be hard to come by. They need to be rewarded appropriately, even when this means paying them more than the Prime Minister gets paid (£150,000). Sadly, the old adage that’s goes something like ‘if you pay peanuts, you get monkeys’ is still relevant today.

Doctors, health and happiness: is this the road to Norway?

Last week, I was the Internal Examiner for one of the School’s PhD students. It’s always a privilege to be part of an individual’s doctoral journey, and it’s always interesting to hear the results of their research. This thesis explored the effectiveness of ambulatory emergency care, a very topical subject. She did well and I’m sure her research will broaden our understanding of how this area of health care gets developed in the future. Ambulatory emergency care is one of the ways that the ever-increasing demand for health care can be met, both in primary care and in addressing the needs of an ever-growing elderly population, who live longer with often very complex health care needs. More of which later, first a slight detour.

My drive back home from the viva was interrupted by a long traffic jam. As I sat there, my mind wandered, and I thought about one of my PhD students who lived and worked in Hungary. I had met him at a conference in Slovakia a few years earlier and he had approached me to see if I would supervise him. Courageously, he wanted to undertake his PhD in English. Over the next three years we had a great time, me popping across to Hungary and he coming across to the UK for supervision sessions. He was awarded his PhD in 2006. A year later he invited me and my long-standing collaborator and writer, Professor Sue McAndrew to visit him as part of an education exchange (and I also think to say ‘thank you’; Sue spent many an hour coaching him with his written English). 

Of the many things we did, two things stand out in my memory. The first was a visit to the Semmelweis Museum of Medicine. It is an absolutely fascinating place and it has one of the best Clemente Susini anatomical wax sculptures to be seen anywhere (although not to everyone’s taste, see here). The museum is housed in the childhood home of Dr Ignaz Semmelweis. He is best known as the Father of infection control, and antiseptic techniques. Working as an obstetrician and surgeon, he made the connection between hand washing and infection. His work at the time saved many lives, but it was not recognised due to a lack of scientific evidence. He endured many years of ridicule and was ostracised by much of the medical profession of the time. Ironically, and very sadly, he died in a psychiatric institution from what we would now know as sepsis, some 14 days after having been severely beaten on his admission. His work was later recognised as ground-breaking when Louis Pasteur and Joseph Lister provided the underpinning science to the ‘germ’ theory of disease. 

The second thing that stood out in my memory was meeting a whole bunch of medical students from Norway. They were studying medicine (in English) at the Semmelweis University. The University has over 230 years’ tradition of providing medical education and its Degrees are recognised worldwide. The Norwegian students were very pleased with their experience, particularly as the Norwegian government paid for all their fees, accommodation and travel. It is their investment in the future as whilst the economic climate is good in Norway, the number of doctors (and other health care professionals) is very low. 

It’s an investment in national health and social care that seems to be paying off. The latest Hartford Ageing Index report, developed by Columbia University, shows Norway as being the best place in the world to be if you were growing older. The index measures a number of different social and economic indicators that reflect the status and wellbeing of older people in a country. These elements include productivity (connectedness within and outside the workforce); wellbeing; equity (the gap between wellbeing and economic security); cohesion (social connectedness); and security (measures that support retirement and physical safety). Norway was ranked top, followed by Sweden, the USA, the Netherlands and Japan. The UK was ranked 11th. Norway also came third in the latest World Happiness Report rankings, whereas the UK was ranked 15th. Finland was ranked No 1 and the least happy place in the world was South Sudan.  

And so back to the UK’s growing ageing population. Last week the think tank Policy Exchange published a report entitled  ‘21st Century Social Care: What’s wrong with social care and how can we fix it?’ It is worth a read. It notes that like many other countries, the UK faces a serious demographic challenge. In 1991 some 15.8% of the UK population were aged 65 or over. This rose to 18% of the population by 2016 and is expected to rise to more than a fifth by 2030. This group in society is the one where increasing numbers of individuals are living with complex health needs, requiring integrated health and social care responses. 

The report notes that in the UK, some 410,000 people live in 11,300 care homes operated by 5,500 providers. 95% of these beds are provided by organisations in the independent sector. Many of those using these services are paying for their care themselves. And that is just those that are easily counted. As the Mirror and Mail newspapers pointed out last week, there are around 690,000 people living with dementia in England and over half of them pay for their own care. Their tabloid headlines of the £25 billion cost was actually quite accurate. The Alzheimer’s Society report that the cost of dementia is around £26 billion a year with only about £10 billion being paid for by the NHS. It suggests that on average, it costs £100,000 for an individual’s dementia care. And don’t get me started on the cost of unnecessary days that many individuals spend in hospital when they are physically well enough to go home, but where the necessary social care is not available.

In the last few weeks I have heard the Chair of the CQC, the NHSIE Regional Director, the NHS Providers organisation, 2 CEOs (and 3 want-to-be CEOs) all talk about the need to move away from hospital centric care, and to think how we can best develop neighbourhood approaches where the whole health and care system can become more integrated in providing the care that people need. I’m getting dangerously close to that 18% of the population and it would be good to see some real action in moving things forward!