May 12th 2020 might have come and gone, but our Ruth is still here and making a difference

Well it was fairly predictable. From midnight last Friday Blackpool was put into lockdown. We have enjoyed good weather over the past few weeks and the resort was the only part of Lancashire not to have been in lockdown. Whereas J and me have been careful to get out on the hills at weekends, many others have simply flocked to our beaches and so it’s not a surprise to see the rate of infections rise.

What did surprise me though was the rise in Covid positive cases in Shetland. This group of islands lies some 110 miles from the Scottish mainland and is home to nearly 23,000 people (which also surprised me). It is a place that in my most romantic moments (yes, I do have them), I’ve thought would be a great place to live. In total there have been 60 Covid positive cases there, including three new cases last Friday. I stumbled across this information and in my follow-up came across the very informative online Shetland News. If you have a spare 30 minutes or so, have a look. It’s a very different but delightful world up there. But even on an island in the middle of the North Atlantic, Covid19 is to be found.

I once had a student who lived and worked on the island. He was a nurse undertaking a distance learning degree in leadership. Each student had to attend for one day at the start and end of each module. He never missed once, despite the journey being long, and at times arduous. I wondered what he was doing now, as I was reading an article in the Nursing Times about funding being made available to ‘accelerate’ the recruitment of overseas nurses. Rather like the ‘Windrush’ generation, who travelled to the UK from Barbados and Jamaica in the early 1950s, the NHS is once again recruiting nurses from overseas countries, notably India this time around.

Whilst the NHS People Plan clearly acknowledged a continuing commitment to international recruitment of nurses, the Covid pandemic almost completely stopped many growing overseas recruitment programmes. Indeed, as I write this blog, there are over 6,500 international nurses who have been recruited to come to England, who have not been able to travel to the UK. Despite what you might read in the papers, apparently these problems are easing, and the Government have made funds available to pay for flights, support during quarantine periods, accommodation and training so these nurses can become UK registered nurses, and goodness do we need them. The National Audit Office notes that currently there are some 44,000 nursing vacancies across the UK.

In recognising this huge vacancy challenge, PM Johnson promised the NHS would recruit 50,000 new nurses by 2025. It’s an ambitious target for sure. However, simply recruiting from overseas is not a sustainable approach to solving the nursing shortages. It is also not always ethical. We should not be recruiting international nurse at the expense of health services in their own country. At one of the Trusts in which I have a NED role, we have long run a ‘Learn, Earn and Return’ approach to recruiting overseas doctors, something extended to nurse recruitment. Everyone wins.

Closer to home, universities have seen a 22% increase in students of students on nursing degree programmes, which represents an additional 5,000 nurses commencing their training than in 2019. It’s a promising start. Perhaps combining overseas recruitment, apprenticeship schemes, and increased nursing degree students, there is a chance in the medium term, to get the much-needed numbers of nurses working in the NHS. Time will tell, but personally, I think, I wouldn’t hold your breath.  

All we need to do now is keep the nurses we have, and reduce the numbers of nurses leaving the profession. The Kings Fund, in a three year study found that 28% of newly qualified nurses leave the profession within 36 months of completing their pre-registration education and training. It is perhaps easy to see why. In most places the norm for many nurses are still 12 hour shifts. Pandemic working, with the donning and doffing of PPE will have accentuated the impact of working such long and unsocial hours.

As the numbers of Covid patients being admitted into hospitals have decreased (but watch this space as unfortunately the numbers will begin to grow again in the very near future), some of the measures put in place for staff have been discontinued. I call this the post-free carparking era. For example, in the last 6 months staff have been able to park, free of charge without any problem. The last few weeks have seen the return of visitors to car parks and the re-introduction of car parking charges for staff. Now, trying to find a car parking space can be that singularly unlooked for and unwanted stress at the start of a long shift.

There is much more that needs to be done to sustain and support our health and social care workforce. Organisations need to keep in place those pandemic support systems. As a people service, we should spend as much time looking after our people as we do looking after those who need our help and care. This was a topic that formed part of a conversation I had with a friend and colleague, Andrew Foster.

Last week we met up for a socially-distanced drink, beside a slow-moving river and a fast-moving M6 motorway. Andrew had led on the recruitment of the doctors and nurses who volunteered to return to the NHS at the start of the pandemic. Some 45,000 people responded. 13,000 were nurses. 6,000 went on to gain their right to register as a practising nurse. He talked of an idea that caught my attention, but it was one that apparently didn’t get off the starting blocks – a reserve nursing workforce – something akin to the Territorial Army reservists. In the continuing battle against Covid19, this seems to me to be an inspired idea, and like the ‘learn, earn and return’ approach, a ‘win win’ for everyone. I hope that Ruth May, who has been known to read this blog, doesn’t find this idea a  complete surprise.      

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 [TW1]

Who will speak up when the chips are down?

 

Between 1996 – 2001, the US energy company Enron was voted ‘America’s most innovative company’. It was truly world-beating, a blue chip company in fact. A blue chip company is generally thought to be one with a reputation for quality, reliability and with the ability to operate profitably in good and bad times. It is the kind of company that you might consider using your grandparents’ inheritance to invest in. So, Enron was a company you could trust. But it wasn’t. It maintained the illusion of profitability through some very ‘shady’ accounting processes, condoned by Non-Executive Directors (NEDs) who were too cosy to challenge such practices.

There was another group that were too cosy to ensure good governance, and that was Enron’s external auditors, Arthur Anderson. Their complicity with Enron, bordered on outright fraud. Yet Arthur Anderson were one of the ‘Big Five’ consultancy and accountancy organisations in the world. The others were Price Waterhouse Cooper (PwC); Deloitte Touche; KPMG; and Ernst and Young. It was a financial scandal that rocked the world. Arthur Anderson were convicted of accountancy and audit fraud and such was the damage to its reputation, the company never recovered.

In a strange coincidence, last week I joined a panel that heard a presentation from Deloitte colleagues who were bidding to become our Trust’s external auditors. It’s a very expensive business and finding the fit with the organisation can be difficult, something one of my NED colleagues was at pains to tell me. He should know, having worked for many years for Accenture, the phoenix organisation that eventually rose out of the ashes of Arthur Anderson. It must have taken a great of hard work to regain the trust that had been lost as a consequence of the Enron affair.

Losing and regaining trust was the focus of another meeting I took part in last week. This was a gathering of NHS NEDs from across England. The meeting aimed to explore the challenge of maintaining public service values in a world which appears to be on the edge of a serious shift in what is acceptable in terms of ethics, truth and accountability; where even abiding by the law seems to have been abandoned.  

The pandemic revealed the extent of this shift. We don’t have to look far to find the evidence. There has been corrupt procurements involving large sums of public money; a non-world-beating test and trace system; the exam results fiasco; inconsistent pandemic advice; a decision to renege on the Brexit deal; and of course, that eye-testing trip to Barnard Castle. And if your missed the story that the Chief People Officer, Prerana Issar, hadn’t heard that there was a problem with staff getting tested, you can read it here. If that wasn’t bad enough, read Shaun Lintern’s story in yesterday’s Independent newspaper.

It seems to me that the very people we should be looking to for value-based leadership are choosing not to demonstrate this, or to step up and be counted. If it sounds as if I’m having a bit of rant, I probably am. I’m angry with the cognitive dissonance that has grown exponentially over the course of the pandemic. Day after day, week after week, the public have been told XYZ, when the reality being experienced is ABC. I only have to think about the problems there were with the supply of PPE for example, to note the difference there was in what was being said and what was being experienced by colleagues working in hospitals, care homes and the community.

Being angry is not a good place to be. It is nearly always destructive and unhelpful. Better to harness the energy that cognitive dissonance can bring, rather than be overwhelmed by it. But as those in my meeting last week noted, to do something, anything, can be difficult giving the prevailing political and societal zeitgeist. However, not to do anything is also unacceptable! I, and I’m sure many more people like me, do not want to be one of those that history shows as doing nothing, while trust, ethics and respect and other public service values become eroded. I’m fortunate to have a voice at Board level within two major NHS Trusts in the north-west of England. I will continue to use this voice to do two things. One is to ask those challenging and sometimes difficult questions. The second is, whilst doing so, to also empower and support my Executive Director colleagues to get on and do what is possible and what is right. If that sounds a bit like what you would expect me to do, just think back to the Enron scenario. Whilst the NHS is not a profit-based entity, there are a large number of ‘must do’s’ that get issued from the centralised command and control top-down approach in place right now.

Some of these are beyond challenging and ambitious (two words I have heard over the past few weeks in justification of these ‘must do’s’). For example, the targets set for restoration and recovery of all NHS services. There is widespread acceptance that these are probably unachievable, and unachievable for very good reasons. Buildings need to be modified to allow for Covid and non-Covid patients to be seen separately; donning and doffing PPE adds a great deal of time to procedures; many patients are still afraid to come into hospital; and there is an almost unmanageable waiting list of people with serious health problems to work through. I don’t believe anyone working in the NHS doesn’t have their patients’ best interests at heart, but these are difficult problems to resolve.

Listening to the swirl of discussion at that NED meeting, and the call for some kind of collective response to the issues raised, I wasn’t left feeling deflated, but more determined to seize every opportunity to push back on what I see as injustice, and the erosion of trust and respect in public service. The Nolan Principles, great in their time, are in need of an overhaul. Perhaps in so doing we could include courage as the virtue that makes all other virtues possible. Whilst courageous speech and action should be grounded in reality, ethics and integrity, it is important too if we want to defend truth, goodness, justice and what is right. This blog is dedicated to my colleague from down the road, Professor Donna Hall, Chair of Bolton NHS Trust, who last week, courageously and very publicly, spoke ‘truth to power.’

How fair is a garden amid the trials and passions of the NHS*

The other day my youngest son, Joe, sent me a text: ‘Gardeners World episode 24. One of your kindred spirits’. – it was an intriguing text. Now I have not watched this programme for many a year. I consider myself a fairly good gardener. But ask me the name of a plant and there is only a 50% chance I will get the right name. I’m of an age where I can’t be bothered with those apps that enable you to identify plants. Life is too short. I’m more interested in the design and production of a garden. And goodness I have almost lost count of the number of gardens I have designed, enjoyed and then left to others to enjoy. I think in the past I found the Gardeners World presenters rather patronising, so stopped watching.

This was a great heads up from my son. The ‘kindred spirit’ was a young man called Arthur. His tiny London garden was all grown in pots and containers. All his pots were metal, no plastic allowed. It was fabulous, and he was also a chicken lover. He couldn’t keep hens in his garden, so used his Gran’s garden to do so. However, he brought them one at a time to his garden to let them eat the weeds between the paving stones and the undesirable insects. He might have been a younger me.  

And then there was another Joe. Sweet Pea Joe. He grew thousands of sweet peas each year. He said he didn’t love them, but he certainly liked them. His enthusiasm was infectious and his calmness reassuring. There were a couple of other gardeners on the programme who were equally passionate about their gardens or what they were growing. In a week that felt more turbulent than normal, it was a brief oasis of calm and I loved the fact that there were folk like these still out there. I might even start watching the programme again.

Someone else I’m glad is still out there is Chris Hopson. He’s the CEO of NHS Providers. NHS Providers is a membership organisation for a good proportion of NHS services including acute hospitals, mental health and community services and ambulance services. Like the gardeners mentioned above, NHS Providers are passionate about finding new ways to help organisations deliver high-quality patient-focused care. They are an important voice in challenging and helping to shape policy. Their team is very effective in communicating and commenting on healthcare issues. Their commentary on the management of the pandemic has been simply outstandingly brilliant. Regular readers of this blog will perhaps recall my despair at what I thought were the trivial questions posed by journalists at each of the Covid-19 daily briefings. Last week’s Downing Street briefing was no exception!

So, I was really pleased last week, to be able to attend the virtual Chairs and CEO’s meeting at which Chris provided an armour-piercing analysis of the current state of affairs and what the future might hold for the NHS. The meeting was under Chatham House rules and so it would be inappropriate for me to attribute any of the discussions to particular individuals. That said, Dido made an appearance to talk about Test and Trace. Although she was as passionate as the gardeners Arthur and Joe about what she was trying to achieve, the task is a clearly a very difficult one. I was left thinking that getting an effective Test and Trace system in place before Winter will be a real challenge.

Indeed, listening to Chris Hopson’s presentation it was clear that the next 6 months are going to be a challenge for all those working in health and social care. Many staff are exhausted. A lot has been asked of all those working in health and social care services, and they have delivered. However, if we are to restore services, more will be asked of these same colleagues. The ask will be even more difficult as as we move into Winter, a time that is traditionally challenging for the NHS with high demands on healthcare services. And that’s before we factor in a second Covid-19 spike, Brexit, the impact of the forthcoming Comprehensive Spending Review, and the possible publication of a new NHS Bill.

Increasingly, looking after our staff is a critical issue. There is a need to think differently about recruitment and retention approaches, with flexibility being a default position. We should be doing more to ‘grow our own’ future workforce. Finding new ways to help individuals stay resilient, motivated and healthy will be crucial if we are to avoid a depleted and depressed work force. Likewise, the place-based (and to a lesser extent, system-based) leadership seen through the pandemic will need to continue as these challenges mount up. Over the past 6 months, a stable financial underpinning of NHS services helped this leadership empowerment, but it is unlikely such stability will be sustained.

It’s perhaps interesting to note that it was providers not commissioners that led the way with so many innovations and new ways of working through the disruption of Covid-19. That work continues as services are slowly being restored. One of the ‘take home’ messages for me from the NHS Providers meeting was that more of us should be shouting out that the NHS glass is two-thirds full and not, as it is sometimes portrayed in the media, as being a glass that’s two-thirds empty.

As I write this, I am reminded of our new garden. Something J and I put a great deal of work into these past 18 months. We wanted to create our own little oasis of colour, shape, smell and sound. I think we have done well in the time available and we have spent many an hour out there enjoying the fruits of our labour. Then, earlier in the year, in just a few hours we had a storm where the winds were so fierce much of the garden was wrecked. Over the past few months, it has slowly recovered, and although there is a Winter to still get through, I feel sure that the NHS, like our garden, will also recover and be even better than it was before the pandemic.

*apologies to Benjamin Disraeli

Tackling the climbing numbers of people attending A&E: 111 First

Last Monday was the Autumn Bank Holiday. In the UK, it is the last Bank Holiday before Christmas Day. As it was due to be a bright warm day, we had decided to get up early, beat the crowds and go to the Lake District in South Cumbria. We fancied doing a bit of hill walking. I wanted to do a walk in the Langdales. The walk we decided upon started at Dungeon Ghyll and goes up to Stickle Tarn and Pavey Ark. It was a walk I had last done some 25 years ago. At that time, I would gleefully scramble up the rocks in the river rather than use the path. Now a quarter of a century on, I took the sensible if rather steep path. But TBH, I had to stop for a breather on a few occasions along the way up. Getting to the top and seeing the views made it worthwhile, however. In the early morning sunshine, it was simply breathtakingly beautiful.

I thought sitting by the water’s edge might be a good place to have our picnic lunch. Then J pointed out it was actually only 9am. We had eaten our breakfast a few hours before, but no matter. We decided to continue the walk around the tarn and up to the summit of Pavey Ark before eating.

There are two or three ways of getting to the top. Two routes involve more steep walks around the mountain and the other way is to clamber up Jack’s Rake (pronounced Jake’s Rake). Now the only sport I have ever been halfway good at is rock climbing. Having last been up Jack’s Rake 25 years ago, I was keen to take another shot at it. I think it’s fair to say that J didn’t share my enthusiasm. I reminded her of Maya Angelou’s words: ‘Having courage doesn’t mean we are unafraid, having courage and showing courage means we face our fears; we are able to say I have fallen, but I will get up’. Given that we were about to climb up a side of a mountain, it perhaps wasn’t a good idea to mention falling.

Indeed, over the past few years, four people have fallen off Jack’s Rake and died. It is a little tough in places and I had forgotten just how very exposed it can be. In places you are walking on extremely narrow ledges, with a fall of hundreds of feet just a missed step away. You can get a sense of our climb by watching this YouTube video.  It was J’s first time scrambling/rock climbing and she did exceptionally well. I’m sure, like me, Maya would have been proud of J facing her fears… …not falling off helped as well!

Once back on ‘terra firma’, and with the large promised G&T in hand, we did wonder who would be there to help those who might get injured on their walks and scrambles. Many parts of the Lake District are remote and far from local emergency services. Last year the various Mountain Rescue Teams were called out to over 500 incidents, and for many years now there has been a rise in the number of deaths of people out walking or climbing on the hills. I’m the first to acknowledge the courage of all those who go out, often in dreadful weather conditions, to search and help those in distress, lost or who have been injured. These folk are all heroes.  

Closer to home, last week I heard an update report of our ‘111 First’ pilot. NHS 111 First is part of a new national programme aimed at improving people’s experience of urgent and emergency care. It is part of the approach to keep people safe when they access help from their local health services. Crowded A&E waiting rooms must become something we don’t return to. But already at Blackpool Teaching Hospitals, we have seen a steady rise in those presenting at A&E for non-Covid reasons.

Many people seem to have lost some of their (Covid-19) fear about going to hospital. Last week, the number of people attending at our emergency department was close to 75% of where they were prior to the pandemic. The same is true for many Acute Trusts across England. However, research has consistently shown that 30% of people who arrive at an A&E department don’t need to be there to have their health needs met. The 111 First programme aims to ensure individuals can be seen by the most appropriate healthcare professional in the most appropriate healthcare setting for their needs. The programme is being piloted by one hospital in every healthcare system across England. Blackpool Teaching Hospitals was selected for the Lancashire and South Cumbria integrated care system.

Patients are asked to contact NHS 111 before they set off for the emergency department. After assessing the individual’s needs, NHS 111 will then book them into a time slot at the emergency department or at some other local service. Of course, all those needing to be ‘blue lighted’ to a hospital will still be taken there by ambulance (or perhaps by helicopter if you happen to be walking in the Lakes). If the pilot sites evaluate well, the programme will be rolled out to every Acute Trust in England.

Booking a slot to be seen at A&E might seem, for some people, counter-intuitive. If you need urgent care and attention, then traditionally A&E is where people have gone. The truth is that many people could get the healthcare they need in many other ways. And that’s the rub. Primary and community care services are often not fully integrated with Acute hospital providers. Gaps in what might be available and accessible to people are many, particularly for those seeking help for mental health problems. Naturally, in such situations, many people will pitch up at their local A&E confident in the knowledge its doors will be open 24-7.  

The pandemic has taught us many things. Healthcare can be accessed in many different ways and from many different places. Hospitals are moving closer to patients’ homes. Most importantly, more is being done to prevent people even needing healthcare services in the first place. But much more could be done to help people help themselves. There is a parallel with what’s happened in the Lake District post the Covid-19 lockdown being eased. In late July, Cumbria Police and Mountain Rescue teams reported a ‘tidal wave’ of avoidable rescues caused by folk venturing out onto the hills who were unprepared or ill-equipped to deal with the weather or what they were attempting to do.

And yes, dear reader, with hindsight I know taking J up Jack’s Rake probably falls into this category. But despite a couple of hairy moments and a few tears shed, we survived and live to tell the tale. Would I do it again? It’s a great question, one faced by anyone who might order another pint, smoke one more cigarette, have that extra large portion of chips or tell themselves there is no need to keep active. If we are to truly tackle the climbing numbers of people attending A&E, the answer has to be a resounding no!