Hearing the hidden voices and speaking truth to power

 

It would have been almost impossible to miss the various stories about voices last week. There were many. However, the one that stuck in my mind in particular was the enormous efforts Amazon have gone to ‘educate’ Alexa over the various dialects and terms used in different parts of the UK. If you did miss it, you can read about Susie Dent, lexicographer, and her work with Alexa here. It’s clear that as technology advances, the everyday world as seen and experienced by others, becomes easier to understand – more of which later.

Now, if truth be told, I have been known to raise my voice slightly at Alexa. On rare occasions I have even used the odd word I wouldn’t want my mother to overhear. Why? From sheer frustration when for whatever reason Alexa doesn’t understand me. Conversely, Alexa is sometimes treated like a member of the family, and she gets thanked (for example, telling me my 20-minute timer is up). Billy the parrot is fascinated with her. He has something to say about most things, but thankfully he has only learnt to say Alex. The ‘a’ is missing otherwise I have no doubt Alexa would be switched on and off all day long. As it is, he speaks with the Radio 2 presenters, and often I will come in and he’s chatting away to the radio – but with the exception of the odd recognisable word, most of the time none of these conversations make much sense.

However, these are voices that are heard. Last week I took part in a very challenging webinar, organised by the Primary Care Journal and Public Policy Projects. The focus was on ‘hard to reach’ groups, using the provision of dental care for homeless people as a means of getting into the issues. Hearing about the innovative ways people have found to provide oral health care was fascinating. I hadn’t appreciated dentists often categorise folk into three different groups: those in pain; those who have regular six monthly check-ups; and those who want a smile. The last group are also not who you might think they may be.

During the webinar several case studies were presented of people whose lives had been impacted by the use of drugs, alcohol, homelessness or poverty. Often for these people, buying a toothbrush and toothpaste wasn’t high up on their list of priorities. Many had experienced enormous difficulties in gaining access to any primary or community health care. I did smile at hearing one of the participants, a dentist, describing how he had to take off his white coat to become a person before he could reach out to these groups of people. But they were doing great work, and helping people regain their smile, which in turn boosted self-confidence, leading to many folk being able to turn their lives around for the better.

What was also clear, however, was that for every individual helped in this way, there are plenty more people out there with similar problems. Last year there were over 14.3 million people in the UK living in poverty and a further 320,000 people who were homeless. The Covid-19 pandemic is inevitably going to exacerbate this situation. As one participant in the webinar noted, these aren’t so much ‘hard to reach groups’ as the groups we often choose to ignore. Their voice is hidden and as such not heard.

Additionally, there is another group whose voice is sometimes ignored. These are the people who don’t own a smartphone, or have access to a computer. Whilst latest estimates note that 95% of the UK population own a smartphone, that missing 5% represents over 3,400,00 people. Increasingly we see the use of such digital technology becoming commonplace in our everyday lives. And whilst I might sometimes get frustrated with Alexa, it’s nothing compared to my frustration when trying to resolve an issue or a problem and not being able to find a phone number to actually speak with someone. Going on-line and using chat boxes, FAQ and so on, or waiting for email replies that never come increases my frustration. Even if there is a phone number, the pandemic has meant there are fewer ‘phone associates’ to handle the calls, so waiting times become almost unbearably long.

But that is nothing like the issues faced by those who don’t have access to new technology. Indeed, they may not even know what it is that they don’t know. They are not alone. Last week GP Helen Salisbury writing in the BMA, noted a problem with remote consultations being the ‘unknown unknowns’. You don’t always know what you are not seeing. Secretary of State for Health and Social Care, Matt Hancock, has said that in the future, all GP consultations should be done remotely by phone or video unless there are compelling clinical reasons not to do so. Although Helen describes doing her best for patients during the pandemic using digital communications, she notes that where there have been successes, it has been a result of the knowledge she has gained of her patients over many years.

She makes a compelling case for a more balanced and nuanced approach to be taken with patient consultations as the pandemic lockdown measures ease. You can read it here. To me she is a good example of someone speaking truth to power. Helen might even consider making an application for the role of Chief Executive of the newly created National Institute for Health Protection. In the ‘Position Specification’ (note it’s position not person) the successful candidate’s profile needs to ‘demonstrate credibility and confidence to speak truth to power; they will have the stature and interpersonal skills to advise all levels of national, regional and local government with an objective and independent mindset’.

I think Matt is possibly in dire need of someone like Helen to help him understand he actually doesn’t need to change the law, so that nurses can give flu vaccinations this Winter. They have been doing so, and very successfully, for many years. But perhaps like others, their voice is hidden and not heard too.

 

Please note: the Alessandro Bianchi/Reuters mask pictured above is not suitable for Covid-19 use.

Goodbye Mr Chips? No Sir, It’s About Love

When I was thinking about this week’s blog, for some reason I conflated in my mind two different films. I was thinking about ‘To Sir with Love’, and the 1967 film, but in my mind, I kept seeing it as ‘Goodbye Mr Chips’, a film first released in 1939, (although I saw the 2nd version released in 1969). They are both great films (and you can still get them on Amazon) but I wonder how many of this blog’s readers have seen either of them. If you have, you may well understand why I was thinking of them this week. But first, a question: Have you ever had a canary?

Up until last week I would have had to say no, but we agreed to look after one while our neighbours took a holiday. It arrived and I was given explicit instructions on how to care for it while they were away. I didn’t say anything, smiled and gently ushered them out of the house. Now having looked after Billy, an African Grey parrot for over 25 years, I felt I was probably fairly capable of looking after a little canary. However, what I didn’t factor in was Muffin.

Muffin is our cat. She is a fat cat, but an excellent mouser. She sleeps all day and goes out at night, come rain or shine, to do whatever cats at night choose to do. She loves Dylan our dog, is not remotely interested in the hens or goats and has never shown the slightest interest in Billy. One might even describe her as an aloof cat. Upon the arrival of the canary, all that changed.

I had put the said canary’s cage on our dining table. Usually this is somewhere completely ignored by Muffin. However just some ten minutes in, and there she was, on the table prowling around the poor canary’s cage. To the tiny canary, Fat Cat Muffin must have seemed terrifying. But fair play to the plucky bird, she just sat there chirping away and completely ignoring the cat. Over the week Muffin never gave up try to get to the canary. I was pleased that nothing happened and the canary was duly returned to her owners unharmed.

The cat made me think of my last PhD student. She completed her studies last week and is now a Doctor. When I first met her, some three and a bit years ago, she was like Muffin and I was like the canary. She had wanted me as her PhD supervisor and was not going to take no for an answer. I was, up to that point, not wanting to take on another doctoral student as I had intended to retire, before any new student could have completed.

At the time I worked in a security-controlled building and for days on end I would get a message from the reception folk to say there was someone here who wanted to speak with me. Much to my shame, I kept repeating that she needed to make an appointment and that might take some time. She had given her name, one I recognised from many emails she had sent me enquiring about doing a PhD, and the situation went on for the best part of a week. In the end I agreed to see her with a view to letting her know that I wasn’t taking on any more students, but I would help her find an alternative supervisor.  

When she did arrive, she asked me to read her proposal, set out over six pages or so. I did and thought it was a very interesting idea. B was from Saudi Arabia and her study was to focus on how female nurses experienced and dealt with the violence they received from the female patients they looked after. She said that after reading much of my work and after taking to other former students, she only wanted me. It was a dilemma. In the end my co-author, fellow academic and best friend Professor Sue McAndrew agreed to be part of the team so that when I retired, B would have some supervisor continuity. As it happened, I stayed with B until the end (although Sue did much of the heavy lifting).

Last week B completed her studies and will be awarded her well-deserved doctorate. She was the last of 21 students I have supervised through to completion. I am really pleased to say not one of my students has ever failed. In addition, I have examined 36 students, none of whom I knew, but whose work I have acknowledged to be an absolute contribution to knowledge and our understanding of life. All these experiences have been a great privilege to be part of, and I have such great memories of each of these individual journeys.

However, it was also an ending for me too. I felt very much like Mark Thackeray and/or Mr Chipping. The last tangible link to the University, my time as Dean and all the students and academic colleagues I had worked with and met over so many years, had gone. As a Professor Emeritus, I can of course continue to be part of a PhD supervisory team, but that is not the same as having that awesome responsibility of guiding someone through their ideas, helping them develop their research skills and of finally being able to help them achieve their dream and contributing to our understanding of the world. That is a special place to be in and one I have cherished for over 20 years.

Its probably time to let the next generation step up to the mark. They have the energy I once had, the audacity to challenge in a way that for me has been blunted by experience, and above all else they have the opportunity to inspire others, something needed in both academia and practice. So, as you might be able to see, by the middle of last week I was feeling more than a little sorry for myself. Two things changed that. The first was a phone call from someone I admire. They rang to let me know of their support of my challenge in a situation where there was otherwise a deafening silence. Since then, support for my challenge has gained momentum from many different quarters and I am confident the situation will now change.

The second thing was a very interesting discussion I had with someone who is seeking to make an application for a top job in the NHS and was seeking my advice. They started the conversation off by saying, ‘you won’t remember me, but you taught me research methods when I was doing my Master’s and that was some 10 or so years ago’. It was a Mark Thackeray rather than a Mr Chips moment. And dear reader, I hope that if you don’t take anything else from this week’s blog, please remember, you absolutely don’t know the impact of what it is you might say and do, both to and for others, and that the impact might stay with them for a very long time. In a world where you can be anything, be kind.    

Love, Sociology and Being Cool

I had a great supervisor for my PhD. He is someone I have mentioned here before, Professor Joel Richman. He taught me a great deal, and he was a giant upon whose shoulders I stood. Standing on his shoulders, I was able to see so much more than I even imagined was possible. He introduced me to sociology, anthropology and the art of writing, something I have grown to love. Joel encouraged me to be bold, authentic, and to find things to be passionate about. He was a great man, a wonderful academic colleague, a total eccentric and a true friend.

He was generous enough to introduce me to his many friends and colleagues during my PhD studies. Many of these were people I had previously only known about from reading their books and articles. For a few years, Joel took me to the Medical Sociology conference in York, where it was possible to have breakfast with those who, to me at the time, were the great and the good. I stumbled across one such person again last week while I was chasing down an evidence citation. His name is Robert Dingwall. Anyone who has studied sociology in the last 25 years will have come across his name and his work. He is semi-retired these days, although he is still a professor at Nottingham Trent University. Robert is one of the foremost international authorities on law, medicine, science and technology, focussing on the work of the professions, the work they do and the organisations they work in. His research portfolio is eclectic and fascinating. His work ranges from child protection, the history of nursing through to energy use and medical negligence. More recently, his previous work on pandemic planning (in the context of the UK experience, that almost feels like an oxymoron) has meant he has been much sought after by Johnson’s Government.

What I found was an article he wrote for the Elder magazine. It wasn’t dated, so I don’t know when during the pandemic he wrote it. Surprisingly, it was entitled, ‘Government coronavirus advice – where is it going wrong?’. You can read it here.  There was one aspect in his narrative that caught my attention, and that was around social distancing. These days it’s something most us of do without thinking, although that said, frighteningly there are also many people who don’t seem to understand what social distancing entails. Robert used this as an example of difficulties that can arise from a Government taking a one-dimensional view when making public policy. I have already elaborated more than enough in previous blogs my thoughts over the lamentable way Johnson et al have managed the country’s response to Covid-19. This time my interest was aroused over the impact (albeit, if I’m being generous) possibly unintentional, on people’s mental health, as a consequence of being ordered to socially distance, shelter and isolate.

The impact on people’s mental health and wellbeing was possibly most experienced by older people. I don’t know about you, but in the early days of lockdown I would notice the absolute look of horror on older people as I walked our dog Dylan – and I’m sure it wasn’t just my often dishevelled look (I call it original chic) that caused the concern, possibly more the fear they would get infected by passing me on the pavement. As a public mental health issue, Dylan and I took to walking early in the morning so as to not encounter too many other folk.

The mental health and wellbeing impact of Covid-19 is beginning to be seen now. Increased presentations at A&E are showing a rise in people presenting with mental health problems. The long- term issues that people might be facing (patients, professionals and all those in between) are at this point unknown. However, experience tells us there is likely to be many people who will experience mental health problems in the future.

Indeed, perhaps in recognition of this new reality, Jo Lenaghan, from Health Education England, was heard in the news last week saying we needed 1,200 additional psychiatrists by 2023, in order to deal with the emergent mental health problems post Covid-19. I’m not sure where she got this figure from. We know that there are 50% more psychiatrists in the NHS than they were some 15 years ago – she is undoubtedly right in one sense, but there are other options. Professor Helen Stokes-Lampard (I so love these impressive names) from the Academy of Royal Colleges takes a different view.

Now you might think, so what? But the Academy of Royal Colleges is an important organisation. They are the coordinating body for the UK’s 23 medical Royal Colleges and Faculties. In this respect they have a unique role to ensure that all of us as patients (and sooner or later we will be patients) are cared for by those who are educated, trained and supervised as they develop their careers. In that sense they are a body whose role it is to make sure we all get the medical care we deserve and expect. So, it was interesting to read that Prof Helen was advocating that in the future we patients might accept that we will be seen by non-doctors. She elaborates further by telling us that these non-doctors will include ‘nurse practitioners’, ‘physician associates’ and ‘social care navigators’. Given that there are nearly 4 million people in England awaiting either an operation or some other kind of treatment, I say, ‘bring it on’.

 But it may be difficult. My parents, both aged around the 90ish mark, complied with the lockdown, embraced on-line shopping, self-isolated, resigned themselves to Zoom and Facetime contacts with their children, grandchildren and even great grandchildren. However, if they wanted health care help, they would want to see their GP. End of. And believe me I have tried to get other professions to help them, but to no avail. Of course, I love them, and wouldn’t see them come to any harm, so I will continue to use what little knowledge I have to try and keep them safe. If I take a step back a pace or two, (and Robert Dingwall might be proud of me) I might think we have been here before and survived. I know you don’t believe me, but perhaps believe the authoritative National Geographic. At a time when we can’t sleep because of the heat, this historical account is really cool!

I’m Lovin’ it: food for thought, is population health the way forward?

It was a ‘food for thought’ kind of week last week. Well actually I was thinking a lot about food, rather than doing too much thinking. I wasn’t thinking about food for myself, but many of the stories I read  had something about food in their content. And there were many of them. I will resist mentioning the development of carbon-free chickens, which in different ways are fed on insects instead of soya or corn. They are allegedly very tasty, and if you are interested in buying one for your Sunday lunch, have a look here. However, when I looked at their website yesterday, I noticed that the chickens (priced £28 each) were sold out.

My favourite food story, however, was about how folk have fallen out of love with the humble sandwich during the pandemic. If you missed it, you can read it here. I thought it was both an amusing and informative story. Mind you it was a little hard to swallow the fact that each of us consumes 200 sandwiches every year. Apparently, in May this year, folk voted the bacon butty as the UK’s favourite sandwich, although I don’t recall anyone asking me.

However, the most obvious food story last week was the so-called ‘Eat Out to Help Out’ or ‘Rishi’s Dishes’ as they are known around here. People can get up to £10 off each meal they buy. They can do this time and time again. The scheme’s so-called purpose is to get the hospitality industry working again by encouraging people to eat out. Takeaways are not included (there is always a silver lining to every dark cloud). Now let me make it really clear, I have not and will not be taking advantage of this new scheme. It’s not that I don’t care about the economy; of course I do. As my mother is often minded to say: ‘there is no such thing as a free meal’. Rishi’s Dishes will of course, have to be paid for by the UK taxpayer. That said, (and I will come back to this point later), I care more about my health and wellbeing than I do about eating out in these uncertain times.  

I’m not alone in this thinking. The ‘Financial Times’ last week reported that since July’s reopening, older customers are the least likely to want to dine in. For me it’s not the risks of coming across someone Covid positive but asymptomatic, but the whole ambience and feel of the place. Whoever is manufacturing Perspex and clear plastic sheets must be making a fortune. But the use of them in places like pubs and restaurants makes me feel we have successfully put the ‘hospital’ into many hospitality experiences, and to be honest, I have enough of the former in my day job!

Likewise, I for one, don’t think that putting ‘hospitals’ at the forefront of how we restore normal health care is necessarily a good thing. And I don’t mean that hospitals are not important nor needed. Of course, they are, but we can also think differently about their place in a future NHS. Last week I was part of a conversation that enabled me to watch and listen to Mervyn King talk about his career. I’m talking about the South African Mervyn King, not the former Governor of the Bank of England. He is famous for the reports he published on corporate governance, and how his work shifted the ‘governance paradigm’ across the world. Now you may think his work has little to do with either food or the repositioning of normality, including what future healthcare provision might look like, but I think you may be wrong. His work has literally influenced and changed the way organisations discharge their governance responsibilities. These organisations range from small companies through to international conglomerates and even global institutions such as the World Bank and the World Health Organisation.

I will come back to that in just a moment, but first Mervyn King and food. Between 1981 – 1989 he was the first Chairman of Operation Hunger. This was an organisation started a little earlier in 1978 by Dr Selma Browde and Dr Nthato Motlana in response to their having witnessed the impact of malnutrition on the South African population and its economy. By 1992, Operation Hunger was feeding up to 2 million people a day! Their work still continues to this day. Using proven methods of community engagement and empowerment, they have built an effective social and physical infrastructure that provides their staff with access to vulnerable people. They continue to work with local communities to create healthy environments for development and growth. You can read more on their work here, but in short, they take a population approach to improving the health and wellbeing of individuals and the communities people live in.  

Which in an interesting way links back to what Mervyn King is better known for. In 1994 he published what has now become the foundation for an immense body of work about corporate governance. This was the King Report 1. It was based on a very different premise of the purpose of an organisation’s Board of Directors. Up to that point, the perceived wisdom stated that a Board’s function was to maximise the benefits for the company’s shareholders. Indeed, it is what I was taught by my MBA tutors. He turned this notion upon its head and thought that in future Boards should learn and better understand what was in the best interests of all their stakeholders and what the organisation might do to enhance the stakeholders’ long-term interests.

This still resonates with contemporary management and governance. Indeed, King went on to refine his original report 3 times, the last of which ‘King 4’ contains 16 principles that might be applied to any organisation wishing to improve how they demonstrate their value to, and understanding of, those who use their goods and/or services. You can read ‘King 4’ here. Interestingly, it was published in 2016, the same year that NHS England published its plans for Sustainability and Transformation Partnerships (STPs), which were the forerunner of the emergent Integrated Care Systems (ICS). And here is some more food for thought. My hope that those involved in developing ICS read and properly digest what ‘King 4’ has to offer. If they do, there is every chance that we might avoid simply ‘reshuffling’ the old health guard and really get to grips with improving the health of our communities.    

Back to the Future Ambitions

I have always enjoyed the early mornings. Long before I started writing this weekly blog, or tweeting as part of the #earlyrisersclub, I would get up early and sit with a cuppa and let the quietness of the day envelop me. It was a great way to start the day, and it was a welcome pause before starting the commute and my workday. Weekends were the precious oases of freedom, and I would rise early so as not to waste a single moment of the day. Even in these days of retirement where every day is like a Sunday, I still get up early and try not to squander the time. And last week I was reminded of a Sunday nearly 23 years ago.

I had been reading the newspapers online and saw a reference to Princess Diana’s death. For some reason, I read that she died on the 31st July 1997. Actually, it was the 31st August 1997. I should know, as on that Sunday 23 years ago, I got up to do a 15 mile sponsored walk. Turning on my car radio, the news was of Diana’s death in Paris. It was early in the morning and so the detail was not really known as to what had happened other than she was involved in a car accident, and the driver and her then partner, Dodi Fayed, had also been killed.

I didn’t hear much more about her death then, as I was to spend the day on the sponsored walk. I cannot remember the charity I was raising funds for, but I think it was one connected to what is now East Lancashire NHS Trust. The walk was on the unopened M65 motorway extension that connected the M65 to the major M6, M61 junction. It had been a controversial road build with many clashes between security staff and ‘eco warriors’ as they tried to halt the building work. On that Sunday there were just the walkers and walk marshals. I can remember it being a bright sunny day, but conversations were sombre and muted as people discussed the news.

Interestingly, the eco warriors won out in the end. The motorway was officially opened in the December of that year, but shortly after it opened, the tarmac had to be relaid with a quieter version, as the road noise was so great it stopped birds of prey (particularly owls) from foraging effectively! The motorway was opened by the erstwhile Home Secretary, Jack Straw. He was a member of Tony Blair’s Labour Cabinet. As it was a year of celebrations recognising 50 years since the NHS came into being, 1997 also witnessed the publication of the New NHS; Modern, Dependable White Paper. The White Paper was ambitious and promised more new money, moving money from bureaucracy to front line care, integrated care, with an emphasis on primary and community care and greater use of new technology to make health care provision more effective.

It may be 23 years old now, but it is still worth a read. You can do so here. Why do I say that? Well last Friday, at 16.30.07 precisely, NHS England and NHS Improvement (NHSE&I) published its long awaited ‘letter’ setting out the Phase Three NHS response to the Covid-19 pandemic. It also makes for an interesting read, see here. Now my J, who is a communications expert, says one should never publish anything late on a Friday afternoon, other than if you don’t intend people to respond or it’s bad news (or both). However, on this occasion, the letter was long-awaited, its publication being promised weeks ago, and I expect many NHS senior managers have been poring over its content since it dropped into their inbox.

Like the New NHS White Paper, the NHSE&I ‘letter’ is ambitious. Its aim focuses on 8 clear areas for action, which together will; accelerate the return to near normal levels of non-Covid-19 health services; prepare for Winter demand pressures, including probable further Covid spikes; lock in the beneficial changes achieved during the first peak, and support the future action on inequalities and prevention. As with the New NHS White Paper, there is also guidance on how finances will be handled going forward to the end of this financial year – Unlike the New NHS, the sums of money involved are phenomenal and completely dwarf that spent 23 years ago on improving the NHS.

There is a recognition. up front and centre, of the importance of supporting all those who work in the NHS, whatever their role. This was something emphasised by Matt Hancock, Secretary of State for Health and Social Care, in his speech to the Royal College of Physicians last week. You can read the transcript here – it’s full of little homilies ranging from the Great Fire of London, town planning in Finland, the Battle of Trafalgar, Ikea car parks and the Road to Wigan Pier. I think his speech writers had a competition going to see who could get the most diverse and interesting historical facts into his speech. But in fairness, his ‘7 cultural lessons’ of how the Covid -19 pandemic has up to this point been responded to and how we might create a future healthcare service that builds upon these lessons was an ambitious look into the future.

However, and despite the recognition there has been of the critical importance of only being able to achieve these ambitions if we have the staff to develop and deliver the future services, I think anyone reading Sir Simon Stevens’ letter will be disheartened. As has been noted elsewhere (see here for example), like many people, lots of NHS staff are exhausted, anxious and worried about the future. The adrenaline-fuelled response to the early pandemic demands has long since dissipated and been replaced by the realisation that we will be living with Covid-19 for a long time.

I wrote and had my first ever paper published in April 1998, just a few months after the New NHS White Paper was published. It took as its focus, the challenges and opportunities there were in the NHS to achieving the White Paper’s ambitions. 23 years on, those challenges (and opportunities) remain – it’s about nurturing staff, embracing change, promoting compassionate leadership and integrated partnerships, supporting innovation and fully utilising all the benefits there are from new technologies. Above all else (as the New NHS White Paper said all those years ago) there should not be a return to the old centralised command and control systems of the 1970s. Sadly, I didn’t see that in the NHSE&I letter.