One flu over the family’s nest

Last Thursday afternoon, I discovered that two of my brothers would, for a brief moment in time, be at my parents’ house in Cardiff. I hadn’t seen either of them face to face for a number of years and we had not all been together for much longer. I guess like lots of families, we have, over the years moved around the UK and further afield. Whilst digital technology means it’s easy to keep in touch, busy lives often meant meeting up was difficult to make happen. It was an opportunity too good to miss. So, I cancelled my plans for Friday and J and I drove down to see them.

Getting up early we left and, despite the rain and very poor driving conditions, four hours later we were sitting in my parents’ house drinking tea and playing catch up. One of my brothers now lives in Bulgaria and loves it. He retired from the Metropolitan Police 12 years ago and now lives a quiet life in a small country village growing trees from seed. He says it won’t make him rich, but he’s very content with his life. Health care in his part of Bulgaria is good and, in the main, cheap to access. He pays the equivalent of £8 a month for his health care, which is then freely available, although he has to pay for any medication prescribed, which can be extremely expensive.

My other brother also retired from the Metropolitan Police many years ago and now lives in Dorset. He runs a falconry centre with over 100 birds of prey which he trains and exhibits at shows. He does a lot of conservation work and works with many children and young people’s charities. Those birds need a great deal of care. Every day they eat 400 day-old chicks between them; and every day they need to be weighed and handled and, where appropriate, flown.

Last week was also the anniversary marking the passing of one of my other brothers, who died before his time, 12 years ago. As we were all gathered together, it seemed right that we should mark the occasion somehow. In the end we decided to raise a glass of non-alcoholic champagne in his memory, which he would have found quite amusing. In life, he ran many pubs and enjoyed more than the odd tipple at times. Sadly, Christopher had long suffered poor health and died from sepsis-induced organ failure.

Sepsis is a life-threatening condition. The number of people developing sepsis in the UK is rising. NHS England estimates that there are some 123,000 cases each year in England alone. Around 37,000 people die with a sepsis-related condition. Even for those who do survive sepsis, it may not be the end of their problems. Many patients end up living with all kinds of physical and mental health problems. They also have a much higher risk of death for up to five years following a sepsis episode. Research undertaken by colleagues at Guy’s and St Thomas’ hospitals have identified a number of risk factors that might result in death occurring to sepsis survivors. Factors such as advanced age, long hospital stays, being male, and the severity of sepsis on admission all contribute to 15% of sepsis survivors dying with 12 months of leaving hospital.

Early recognition of the condition is vital if sepsis is to be successfully treated. The National Early Warning Score (NEWS) helps health care professionals recognise sepsis and start treatment within the hour. The sooner treatment is started the better the outlook. One of the problems is that sepsis can present in a number of ways and there is no one clear indicator or even a single test that can be undertaken, and diagnosis usually follows an analysis of a number of different tests. Added to this is that sepsis can initially look like gastroenteritis, or a chest infection or even flu.

And here I’m talking about real flu, as in influenza. Flu is a very common, and highly infectious disease. Like sepsis, it can cause serious health problems and even death, particularly for those in high risk groups. These will include young children and older people over the age of 65, and anyone with a chronic health condition involving the heart, kidneys or lungs. Flu epidemics can kill many thousands of people and, in some years, even millions of people. The World Health Organisation estimates that flu kills between 250,000 – 500,000 people around the world every year. The infamous 1918 flu epidemic is estimated to have affected over half the world’s population and killed between 40-50 million people. In the UK, an average of 600 people a year die from the complications of flu. But it's not always the case, and flu can kill people who are otherwise healthy. In the UK flu epidemic of 2008/09, some 13,000 people died from flu-related complications. Every year, flu leads to hundreds of thousands of GP visits and accounts for tens of thousands of bed days in hospital, most of which could be avoided by everyone getting the flu vaccination.

For many people it’s free to do. Increasingly, many organisations are providing vaccinations for their employees, as it makes good sense to prevent people having to take time off work through illness. And even if you are one of those who isn’t eligible, it is possible to get the vaccination for a small charge in lots of different places these days – see here for the ‘best deals’ on offer.  In the UK, the annual flu season runs from October to April. Most cases of flu occur between December and February. The flu vaccination will start to become available from this weekend. I’m having mine on 16th October.

To be frank, I think that everyone in the NHS who is working in a position where they have face to face contact with the public (patients, carers and others) should get themselves a flu vaccination. In Bulgaria, where health care provision falls way behind that expected and experienced in the UK, they are taking flu vaccination very seriously and this year will offer free vaccinations to most of the population. My call out to colleagues is get yourself vaccinated as soon as it possible to do so! And no, you can't get flu from the vaccination!    

  

Kindness, compassion, safety and humility matter

Last week, I had a couple of very stark reminders of just how dreadful the world can be for lots of people. The first was a picture of some street art seen on one of the city walls in Istanbul. It was made up of 440 pairs of women’s shoes. Each pair represented a woman who had been murdered by their husband in Turkey during the year. I found it a stunningly powerful image. Shocking as the facts are, sadly it is not an issue found only in the Middle East. Refuge is a charity committed to creating a world where domestic violence and violence against women and girls is not tolerated, and a world where women and children can live in safety. On their website, they quote from research published in 2016 by the Office for National Statistics (ONS). It makes for an equally disturbing read.

One woman in four experiences domestic violence in her lifetime. Two women are killed each week by a current or former partner in England and Wales – yes that is two women each week. In the year ending March 2016, 1.2 million women reported experiences of domestic abuse in England and Wales. The message here is as equally shocking as the 440 pairs of shoes. The Refuge website is absolutely worth reading to see the work they are doing in holding perpetrators to account, preventing future violence occurring through education and campaigning to change the State’s response to violence against women. Last week the UK appointed the first Domestic Abuse Commissioner, Nicole Jacobs. An appointment made after the numbers of those reporting domestic abuse reached a 5 year high. 

My second picture in this week’s blog comes from the Refuge website. I found it similarly powerful. For me it clearly illustrates why such a commissioner is required. And given her background, I'm very hopeful that we will see some change. 

The second reminder was less stark in contrast, but was equally powerful. On Friday at Wigan, Wrightington and Leigh (WWL), where I am Vice-Chair, I chaired a series of appointment panels for the recruitment of medical consultants. In particular, we were trying to fill vacancies in cardiology and gastroenterology. At a time where there are many shortages across a range of healthcare professions, it was great to see so many candidates expressing a desire to work at our NHS Trust. For each of the posts there were some excellent candidates, some with more experience than others, but all were highly skilled and knowledgeable. I never cease to be amazed at the way in which the clinical scenario questions are presented and the subsequent detailed responses from the candidates. The use of abbreviations and terms, where I had no idea what is being said or what they might mean, was both amusing and reassuring. Amusing because it really does sound like a different language and reassuring because these folk really do know what they are doing!

Each of the candidates was asked to present their own CV in their own words and tell of their journey to become a consultant. One of the candidates, whom I will call Mahdi, a very softly spoken man, started his narrative by telling the panel where he had trained, which was overseas, and how he had come to the UK to gain more specialist knowledge and skills. He had stayed here for a number of years and had made a wonderful contribution to the NHS whilst acquiring these skills. Mahdi eventually wanted to return home. That’s where his extended family lived, and he wanted to use what he had learnt to help those in his own country. The place Mahdi called home was Syria.

The Global Peace Index ranks Syria as 162 (from 163 countries listed) making it the most violent county in the world after Afghanistan. The Syrian Observatory for Human Rights, a monitoring group based in the UK, has estimated that since the start of civil war in 2011, the number of people who have died there has reached 511,000. The United Nations (UN) Commission of Inquiry on Syria has reported that during 2011 and 2017, the rape and sexual violence against women, committed by government forces and associated militias, amounted to war crimes against humanity. Additionally, the UN High Commissioner for Refugees reports that the years of relentless fighting have resulted in 6.6 million people being displaced internally, and a further 5.6 million around the world. Mahdi is one of these people.

Not long after Mahdi returned home the political unrest and conflicts grew to such an extent that he feared for his safety and returned to the UK. He once again started practising in the NHS. With the escalation in the ongoing civil war in Syria, Mahdi once more returned to Syria to rescue his mother and sister and did manage to get his mother out of the country. His sister remains in Syria.

During all this time Mahdi has continued to use his medical knowledge to help others. He told of his experiences of working in Saudi Arabia, and how he found it very difficult to work within the ‘two class’ system of healthcare. Mahdi reminded the panel of how wonderful the NHS was in providing such universal high-quality care whatever someone’s status or resources might be. I was very impressed with his humility and commitment to helping others, despite what he and those he loved had endured over the years.  In so many cases, we absolutely don’t know what those around us have experienced, or continue to experience.

I asked all the candidates the one and only interview question I’m allowed: ‘Can you please give us an example of when you were kind to a patient?’. These days I am no longer surprised by the variety of answers I get to this question. Nearly all the candidates proclaimed themselves as being kind and compassionate in their dealings with patients, and maybe they are. However, some of the candidates struggled with coming up with an example that was truly one that demonstrated the interpersonal and not something that was organisational or procedural. Mahdi was not one of these. Mahdi has and will continue to truly make a difference to so many people. While there are people like Mahdi and Nicole around, there is hope that we can make the world a better place in which to live.

Blue skies smiling at me, nothing but blue skies do I see*

I didn’t much like last week. Like a Dickens novel, it started well with plenty of great expectations to look forward to and my mood was very buoyant. The week ended with disappointment, and my mood became decidedly flat. I was in that miserable place that comes with feeling low, and where for me, even the brilliant firework display, and live music of Friday evening couldn’t lift my mood. That ‘fed up feeling’ was still there when I woke up yesterday and despite the promised sunshine, the day didn’t hold much appeal. Two things changed all that.

The first thing was I had been given the sole responsibility of looking after Hansel and Gretel, our two pygmy goats (or J’s babies) while she went to have her hair done. This is both a great honour and of course a huge responsibility. So there was no lounging in bed for me, as they needed feeding and watering and singing to. Everything about them is delightful and it’s difficult not to smile when you are with them.

The second thing was seeing a tweet from a newly qualified nurse who was sharing her joy about being able to put on her ‘blue uniform’ now she had successfully registered with the Nursing, and Midwifery Council (NMC). She had described the three years as being both exhilarating and hard work, and that she sometimes wondered if she would ever get to the end. There was something in her happiness at achieving her ambition that lifted my heart. For the second time that morning I was smiling.

Over my hot Vimto, I thought about all those students who over the years had started and completed their nurse education at my University (and there are other universities). Over the years there must have been thousands and hopefully most are still working in healthcare and making a difference to the lives of others. And quite by chance yesterday, I also saw another tweet about the work of the NMC. Yesterday, it appears, we were 100 days away from celebrating 100 years of nurse regulation. The tweet was signalling the launch of ‘Always Caring, Always Nursing’ showcasing a century of professional pride.

There new website is well worth a visit. For those interested in history, there are lots of interesting facts – and I didn’t know that the University of Edinburgh was the first in the UK to offer a degree in nursing (1960). There is a fabulous interactive Timeline of the history of the development of nursing as a regulated profession. On the May 1949 entry, there is an extract from the original British Journal of Nursing which describes the Nurses Act and the proposed membership of the reconstituted NMC. One of the roles in the new membership structure would be for someone to represent universities in England and Wales. After a brief foray into what was called the UKCC, the present day NMC organisation was reformed in 2002. Also on the website is a wonderful account of the life and contribution to nursing of Ethel Fenwick.

Hers is a fascinating story, which you can read for yourself here. She started her nurse training in 1878 and had to pay for her own education – and for me, there is a local connection as Ethel worked for a while at Manchester Royal Infirmary, which back in 1752 had a total of just a dozen beds! Now it’s part of the Manchester University NHS Foundation Trust, which is the largest NHS Trust in the UK. Ethel tirelessly campaigned for the regulation of the nursing profession. Indeed, Ethel and her husband actually took over the British Journal of Nursing and used it to promote their campaign. Finally, in December 1919, the Nurses Registration Act was passed. Ethel, then 62, became the first nurse to be admitted onto the Register. She became State Registered Nurse No 1.

I don’t know how many nurses have been registered since. I do know there are currently 698,237 registrants on the NMC register, of which at least 653,544 are registered nurses. Sadly since 2018, my name no longer appears on the register, so I cannot practise as a nurse in the UK. But that doesn’t mean I no longer care. Making a difference to the lives of others is as important to me today as it was when I was still a registered nurse.

Next year is the World Health Organisation’s ‘Year of the nurse and midwife’. The reason for this recognition is to honour the 200th birthday of Florence Nightingale and to look at the world  nursing workforce. Despite the problems facing the nursing workforce in many parts of the world, I think there will also be plenty to celebrate about the profession. Interestingly, Florence and Ethel didn’t see eye to eye over the registration of nursing. Florence thought it would be damaging to the nursing profession. She argued that such a move would prevent many women, particularly those with little formal education, from undertaking nurse training. A century later, we now have many routes into the profession and of course, the new role of Nursing Associate, although with the removal of the bursary, you could say that nurses are still paying for their education and training.   

Finally, last week I got to see the new Greater Manchester Chief Nurses’ uniform. Sadly, I couldn’t get my phone out to snap a picture in time, but my, wasn’t it grand! It was a very dark navy blue with plenty of bright gold braiding on the collar, sleeves and shoulders. It looked fabulous and I can’t wait to see a picture of them all standing shoulder to shoulder as they continue to lead on the development of the nursing profession in the North West. I hope they are as proud to wear their new uniforms as that newly qualified nurse I saw tweeting yesterday.  

*thanks to Ella Fitzgerald      

Safety first is always a good strategy!

The other week I rode my bike for the first time in a very long time. I took it out to ‘ride the lights’ on Blackpool’s promenade. The prom was closed to traffic and the famous Illuminations turned on just for the evening. I was joined by literally thousands of other cyclists. There were families, people in fancy dress, quirky bikes; the whole evening was one big extravaganza of lights, colour, noise and bustle. It was simply a brilliant experience, and one I had been looking forward to for ages. I had never done it before and whilst I had read up on previous years reviews, I wasn’t sure what to expect.

The organisers provided some basic rules for all participants, including that each bike had to have lights front and back. They advised that a helmet should be worn. I didn’t have a helmet and have always preferred to ride my bike without one. A former PhD student of mine, whose study was on cycling, would often tell me there was no conclusive evidence that helmets protect cyclists from death. There are many international research studies that appear to partially support this – see here for an example. The latest data available (2016) shows that in that year, 102 cyclists died in road traffic accidents, compared to 816 car drivers and 448 pedestrians. In terms of serious injury, the rate for cyclists is much higher than for car drivers. This data has remained fairly static for the past five years.

As I didn’t know what to expect, I went out and bought a helmet. It was a safety first, psychological assurance decision – a kind of ‘just in case’ decision. Mind you I was surprised at how much they cost and the huge range of styles. As is my wont, I did manage to find one in a fetching combination of shades of black. However, there were so many people on the ‘ride the lights’ that the pace of travel was very slow, and I never felt in danger of having an accident or falling off. But safety is never an absolute concept and should never be so. In my case keeping safe and getting to the end of the ride was my measure of safety on that occasion, whereas it obviously will change in a different situation.

This was something acknowledged in the recently published report ‘The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients’. Now I might be getting mellow in my old age, but this is actually a really good report to have come from those folk at NHS England/Improvement, and I don’t say that very often! If you haven’t seen the report, give it a read. I liked both the tone and intent of the report. The tone is about all of us working together to continually improve patient safety, something that cannot simply be done through regulation. The intention is that this strategy becomes a ‘golden thread’ running through healthcare. Ok we can let NHSE/I off for that one as it did come from marmite Matt (love him or loathe him, he is still the Secretary of State).

The report acknowledges that patient safety is about maximising things that go right and minimising the things that go wrong. Achieving this aim could save 1,000 extra lives and £100 million in care costs each year. Additionally, the NHS could save around £750 million in compensation costs per year. Back in 2018, the NHS paid out £1.7 billion on negligence claims and the estimated total liabilities, if all current claims were successful, stands at a staggering £65 billion. Whilst these are incentives enough, it’s important to remember that each of these claims has a person, their family and friends at the heart of the matter, and someone whose experience of care was woefully inadequate.

The report makes an important point about the need to change the culture around safety. My long-time reluctance to wear a helmet was a result of an unashamed and ego-driven desire to look good, which in my mid at least was associated with some kind of Easy Rider image, hair blowing in the wind, and born to be free (I know shallow, shallow). These days the thought of having a life-changing accident (or even dying) was more than enough to challenge these perceptions of what was important and what I needed to do to change my behaviour. Having bought the helmet, I put it on and after a little fiddling with my hair, I decided that actually I still looked quite good, and felt quite proud to be doing the sensible thing in protecting myself and those I love.  

I suspect changing the culture in the NHS will be slightly more complicated. More often than not the approach to any mistake made is to hold the individual to account. Do you remember McGregor's (and I’m not talking Peter Rabbit here), Theory X, Theory Y’ approach to managing people? Developed in 1960, in many places in the NHS Douglas McGregor’s theory still holds true. Where the manager’s assumption about how to get results is through control-orientated approaches – namely, we punish people who make mistakes and they then won’t make them again – then the resulting organisational culture is unlikely to improve safety and reduce mistakes! Of course, in those thankfully rare instances where someone is deliberately malicious and/or knowingly ignores best practice or perhaps is even unfit to practice, then the appropriate action needs to be taken in order to protect patients and other members of staff.

Concepts such as developing a ‘just culture’ are actively promoted in many NHS organisations. A ‘just culture’ recognises that many mistakes made by individuals are often the result of how that person interacts with the systems within which they work. Most people don’t come to work to do a bad job! If we continue to look at blaming individuals (even using ‘reflection and training’ approaches to error management) then the systemic issues will never be addressed. Crash helmets have their place, but it’s improvements in our familiar friends: ‘education’, ‘trust’, ‘compassionate leadership’, ‘teamworking’ and ‘system thinking’ that will keep all our patients safe.

Special thanks go to my colleague @Clairea761 who unknowingly provided the inspiration for this week’s blog and who every day, does so much to keep folk safe and well cared for.  

A Mars a Day helps you Work, Rest and Play (other chocolates are available)

I’m on my way to Mars! I shall be there in July 2020. I have my Boarding Pass and I will be sitting in seat number 8006538. Well my name will be there along with millions of others too. You can join me by booking your ticket here. I thought this was a really fun way to gain interest into the latest space exploration challenge. The story also made me think of Mars bars. I know, but it’s the way my mind works sometimes.

These days I occasionally eat one. As a child I ate way too many of these bars and subsequently did irreparable damage to my teeth. Every Mars bar has 230 calories and 12g of fat. If you consider that the average person needs 2000 calories per day, the good news is that’s less than 9 Mars bars. If truth were told, the health promoter in me suggests you should probably stop at 7 bars. My favourite way of eating them is to put the bar into the fridge and slice it into tiny slivers so as to gain maximum pleasure from each delicious mouthful.

The Mars bar first made an appearance in 1932 and was the genius idea of one Mr Mars from the US (the name has nothing whatsoever to do with the planet). It was a very successful chocolate invention. Between 1959 and 2002 Mars used probably one of the most famous advertising lines in history – ‘A Mars a day helps you work, rest and play’. It was a great slogan, even if some of the advertisements were a bit disingenuous. For us vegetarians, there was a bit of a scare back in 2007 when Mars decided to change their recipe and to start using animal products in the manufacturing process. Rennet, a chemical enzyme, extracted from calves’ or young goats’ stomachs is used in many food manufacturing processes, and not just in cheese making. Thankfully, the decision was reversed in double quick time due to the public uproar and a vegetarian version of the rennet was once more used – and this was way before vegetarianism was as popular as it is today.

Over the years Mars bars have been my staple ‘take with me’ food when I was traveling to places where I suspected it might be difficult to get vegetarian food. Although I have always travelled light, I have always found room for half a dozen Mars bars. More than once they have proved to be a great alternative lunch. Back in August of 2015 I was privileged to visit Uganda with colleagues from Health Education England. We visited various parts of the country to see students from my School who were undertaking a clinical placement there as part of their nursing and midwifery training. As is sometimes the way, I didn’t need my Mars bars, although I did eat a large number of omelettes and chips over the 10 days. I mention Uganda here, not just because of the Mars bar connection but because of what I saw when visiting a number of hospitals and community based health services.

There was much poverty. There were shortages of everything. There was dirt and squalor everywhere. There was overcrowding and a lack of privacy. Yet there was resilience, and cheerfulness. There was often great improvisation and creativity. There was knowledge and skill, and there was a commitment to compassionate care. Our students had a fantastic time and benefitted greatly from their experience – but as they were only there for some 12 weeks, I wondered what it must be like to work in the health service there day after day with all the problems we saw. Everyone we met, appeared happy, smiled and certainly didn’t lack energy or enthusiasm. However, I wondered how many of the nurses and doctors were living with common mental health problems such as depression and anxiety because of their working environment.  

Stress, depression, and anxiety are universal mental health problems. They can be found anywhere in the world, and anyone can experience these problems at any time. It was hard to find out any reliable epidemiological data on the prevalence of mental health problems in Uganda, but some local studies undertaken in the last 10 years would suggest that there are high rates of common mental health problems in the many of the city and urban populations. When I visited, mental health services were rudimentary to say the least. I doubt that things have changed very much since then.  

Last week NHS Digital revealed that in England, staff working in the NHS took 17.7 million days of sick leave during the 12 months up to November 2018. Of these 4.2 million days were taken due to stress anxiety, depression or some other mental illness. This figure is more than the next 2 most common reasons combined – musculoskeletal conditions and the ubiquitous common cold. I’m not surprised by these figures. Whilst the NHS has nowhere near the kinds of problems facing those working in the Ugandan health system, for many NHS colleagues, life will feel very difficult. The current shortage of staff, the ever-increasing demands for health care and the resource constraints, can all contribute to individuals feeling stressed and or depressed.

   

Some of the problems facing the NHS are not easily solved in the short term. I believe in the longer term, many of these concerns can and will be addressed. In any event, we need to be mindful of those we work with and come into contact with. We should be on the look out for signs that they are struggling with demands they might be dealing with, even those that may not be apparent to us. Help is there, and even if we can’t provide that personally, we can do much to help others to find and obtain the support they need. Yesterday saw the last day of the #WeActiveChallenge2019. I was immensely pleased to see so many health care professionals rise to that challenge and take part. I hope many of these folk will keep up their new found healthier lifestyle. As Rethink, the mental health charity says, ‘it’s all about the small steps’.

As for me, I was really pleased with reaching my challenge targets – over 200 miles walked, over 1 stone lost in weight, and an almost alcohol-free month. I have a new spring in my step, and not only do I have my ticket to Mars, but I have my tickets for the Health and Care Innovation Expo next week - although I don’t think I will be taking any Mars bars with me.