Sounding the Last Post for 2020: but saying a big HELLO to 2021, where there is much to look forward to!

My last blog of the year is often a strange one to write. In times past I’ve tended to look back at my year and reminisce about what I have done and my hopes for the year to come. In terms of those looking at my blog, it is the worse week of the year for me. The numbers of folk clicking on the link and reading my words dwindles to a few hundred. However, every year I am reminded of the question my father has often asked me about why I write my blog, who is it for, and what am I trying to achieve? Simply put, I write the blog primarily for me. I find I have things I want to say, thoughts that I feel just need to be put out there. Yes, I enjoy writing so my weekly blog post is not a chore, it’s a real pleasure. That other people choose to read it, and so many generously respond and comment is a huge bonus. All such responses are absolutely appreciated, and all are uplifting.

What now seems a long time ago (and it truly feels like a long time) many of us started the year with great expectations. I know I did. It was the year that J and I were to be married. We had planned what we thought was to be an unique event, capturing our love of music, freedom, living the ‘good life’ (aka BBC’s Tom and Barbara) and celebrating all that Mother Nature has to offer us all. But it wasn’t to be.

The wedding date came and went in Lockdown No 1. It took a while for us to get going again. And boy, did we feel guilty. There was the pair of us steeped in a fit of depression over our cancelled wedding while people were dying of Covid-19, and our professional colleagues were working flat out to care for all those who need their skill and help. The ‘happy clapping Thursdays’ didn’t change a thing. We both felt inadequate and anxious that we weren’t really doing enough.

As Lockdown 1 went on, we were lured into a false sense of unreality. The sunshine filled days, hugely compensated for the lack of contact with others. We welcomed Teams and Zoom, as a new and almost magical way of working. Eventually such virtual meetings lost their appeal and accentuated the impotence we felt at not being there, standing shoulder to shoulder with colleagues on the front line. I’m a nurse by professional background and watching and hearing the pain and trauma that other nurses were enduring left its mark.

Here in the North West, the pandemic never really went away. Yes, we had a few days, maybe even a week or two where nobody who was Covid positive was admitted into our wards, but it was a brief respite. During what should have been the recovery months of August – October, we were once more having to deal with increasing numbers of Covid infections and admissions. By the beginning of November, there was a second peak of infections and Lockdown No 2 was put in force. Unlike the first peak of infections, where many non-Covid services were greatly reduced or even stopped, this time around these services continued to be provided. The result was a health and care workforce that became increasingly exhausted, anxious and demotivated. The so called ‘nosocomial’ infection rates started to rise, and hospitals began to feel like unsafe places once more.

However, whilst the rate of infections remains high in many parts of the UK, they have started to plateau in most areas across the North West. So, whilst the pandemic hasn’t gone away there are some hopeful signs. There was much creativity shown during the early months of the pandemic. New and innovative ways of providing services and care were developed. Decision making at a local level became easier and certainly a great deal faster, and, of course, a viable vaccine has been developed.

At a personal level, J and I were able to get married towards the end of October. It wasn’t the wedding we had planned or imagined, but for us, it was a very special day. Thank you to all those who helped make it happen – you know who your are! And as 2020 draws to a close I believe there are also many good things to look forward to in the coming year. Yes we need to get the vaccination programme up and running effectively (no mean feat at all, just look at our world-beating test and trace system), but if we can protect the most vulnerable in our communities I predict the demand for Covid beds in hospitals will fall dramatically by February. Of course, we still need to get through January and that is likely to be tough for everyone.

Also, in the last few days of 2020, one of the things I will remember about the year is growing my network of colleagues and friends through the work of the Good Governance Institute. With great foresight, back in March they set up a regular virtual meeting place. NHS Non-Executive Directors (NED) could use this space to discuss ideas, fears and anxieties, challenge policy discussions and do so within the security of Chatham House Rules. Every Friday morning, I have been able to be part of this community and have extended my NED network to include many new folk from across England.

I had the privilege to lead on one of the meetings that looked at what good governance might look like in the emergent Integrated Care Systems (ICS). I remember suggesting the way forward might be creating a statutory collaborative body that mandated all organisations across the NHS family, Local Authorities and other stakeholder came together to work in a more integrated way. The alternative would be the creation of new NHS statutory standalone body, which to me felt like going backwards in time. So, I was pleased when NHS England published its Integrated Care Systems next steps guidance at the end of November, which also recommended an option similar to the one I had described. 

If the start of the year held great expectations for us, I think equally so, 2021 brings with it some wonderful opportunities to make a difference to the lives of so many of those who make up our communities. I have 4 ambitions for the new year: 1) I want to help improve the health and health outcomes for our communities; (2) I want to find ways to help reduce health inequalities; (3) enhance the productivity of our health and care organisations and (4) develop a stronger and more coherent partnership place-based approach to how care is delivered.

I’m sure you might have similar ambitions and hopes, but whatever yours might be, I wish you all a wonderful start to 2021 and a brilliant New Year. 

Tomorrow is not promised, but we can do a lot more to make it fairer when it comes

My legs are both longer and older than my wife’s J’s. Hers are also considerably prettier. Having longer legs is not usually a problem. I don’t mind fetching things down from the top shelf or holding an umbrella to shelter her when it’s raining, or even moving her car with my legs scrunched up so as not to disturb her seat position. However, other times the leg length difference is a pain and, to be frank, simply unfair. We can, for example both walk the same number of miles, yet she will accumulate an extra 30% more steps on her Fitbit. It’s not like I’m especially competitive or anything, but when steps get counted, gaining extra steps just because you have shorter legs than your companion simply isn’t fair.

It’s not just the difference in leg length that can lead to discord in our house. Putting on or losing the odd kg or two can give rise to cries of ‘that’s not fair’. During our recent kitchen makeover, something that lasted three long weeks, we did, out of necessity, often frequent, the local takeaways. The inevitable result was we both gained some extra kgs. With Christmas just around the corner, we were keen to try and shed the extra weight ahead of the holiday break. We knew we were likely to continue to eat more of the wrong things and probably not exercise as much. So we decided upon a quick ‘let’s be careful what we eat’ approach to our diets. I lost those extra few kg relatively easily and quickly, J not so easily.

But, as he hastily ducks his head to avoid the rolling pin thrown his way, it’s not her fault. It really isn’t. Research undertaken by Newcastle and Glasgow universities has confirmed that men do lose weight much easier than women. The research (The Direct Trial) was aimed at exploring whether a low-calorie diet might help those with type 2 diabetes. The aim was to see if a low-calorie diet could help them lose just 15 kg and do so relatively quickly and easily. The original study, published in 2017 showed very promising results, with 50% of the participants going into remission from type 2 diabetes.

However, the participants were followed up over the next three years. The result of this longer study revealed an unexpected additional outcome. Whilst both the men and women followed the same diet, there was a marked difference in weight loss between the sexes. On average men lost 11% of their body weight. The women, by comparison, lost just 8.4%. It just isn’t fair. Of course, there are many reasons why men appear to lose more weight more easily than women. Men’s general build is different to women. They need to consume more calories a day simply to maintain their weight than women do. Typically, a man in their 50s will need 2,500 calories a day to maintain weight while women will need about 2,000 calories. Usually to lose weight, people normally try and reduce their calorie intake by 500 calories a week. In the longer study, where the men and women were following the same diet, eating the same portions of food, it was obvious (after the event maybe) that the men would automatically lose weight. Which they did, and the women said that simply wasn’t fair!

There are others who perhaps think life is unfair at the moment. In London and the South East for example, I think that pubs and scotch egg producers who have enjoyed such a huge increase in sales of this ‘substantial meal’ recently, will think the new Covid19 restrictions are just unfair. They are not of course, they are lifesaving. If you like scotch eggs, (as I do), you can always make your own (as I do) and pour yourself a glass of something cold (as I do) and sit in your own home and enjoy both.

Last week also saw Michael Marmot publish his new report about creating a fairer society. It’s a challenging report. If you have not had a chance to read it, you can take a look at it here. I have long admired Marmot for absolutely capturing both the scientific and sociological evidence but at the same time presenting this in a way that reflects today’s health inequalities zeitgeist. Greta Thunberg has done something similar around climate change. The title of this latest report, ‘Build Back Fairer: the COVID-19 Marmot Review’, is a very clever riposte to the now familiar pandemic mantra ‘Build Back Better’.

The ‘Build Back Better’ campaign reflects a more economic view of the world, one that perhaps reflects the innovation and creativity that dealing with the pandemic has engendered. There is no doubt that there have been many clever new ways of thinking and working that have been very positive. I hope these remain as we move through the pandemic and beyond. Not to do so would be unfair on all those who have worked so hard and at pace, to develop solutions to the many unprecedented challenges of Covid19, including the global community who have developed the various vaccines.  

This report reinforces the critical messages in Marmot’s Fair Society, Healthy Lives (The Marmot Review), published in 2010. I think its fair to say that many of the social determinants of health identified in his review have largely been ignored by governments since then (and don’t get me started by Cameron’s big Brexit referendum mistake). The pandemic has absolutely exposed the level of deprivation and health inequalities in the UK which Marmot wrote about back in 2010. And like Greta Thunberg with raising awareness over climate change, it took a football player Marcus Rashford to get the UK government to see that there really was something unacceptable in 2020 in having our children going to bed at night hungry.

Is it just me who thinks there is something wrong that, when as a nation we are presented with a major challenge to the world we know and the health of our nation, the government can suddenly find the money to keep people safe and protect the economy, but yet has been reluctant to invest the same amount of money proactively to reduce health inequalities. Against this context, the recent UK policy of austerity feels unfair. Hopefully, as we move towards a repositioned normal, the government of the day will recognise the science (including social sciences) and commit to ensuring a fairer, more equal society. Everybody’s health and wellbeing is important. That’s what building back fairer really means.

This is my last blog posting before Christmas 2020. For many, Christmas this year will be very different. Some may think that is simply unfair, but whilst I will miss our family celebrations, I intend to stay safe and J and I will celebrate on our own, with our goats, hens, Billy the parrot, Muffin our cat and the ever enthusiastic Dylan the dog, who incidentally has even shorter legs than J. And I hope everyone is able to enjoy a very peaceful Christmas. 

Ps. In the interest of fairness I have agreed to have bone-shortening surgery for my legs in the New Year (but maybe just not this New Year).

      

A Nursing Christmas 2020: choices, dilemmas and dinners

For many folk, Christmas is a time to try and come together to celebrate, be happy, share gifts and remember the true meaning of life. I don’t think 2020 will be like that. Last week was difficult in trying to sort out this year’s family celebrations. For many years I have cooked a Christmas dinner on at least three occasions so as to accommodate most members of my extended family. The year before last was slightly different. We booked a giant table at a local restaurant and everyone came for a sit-down meal and celebration. It was a wonderful afternoon of food and fun. Last year it was out with the different family groups, for our various Christmas dinners. This year it will be different again, but not in a good way. The Tier 3 restrictions have impacted upon our (and I guess most people’s) plans for this year.

The Government’s Covid-19 rules don’t help in sorting out what might be the right things to do either. Whilst the Government website rules are clear about who can meet inside - only those you live with or form part of your support bubble - the rules for meeting outside are less clear. On one hand you cannot meet anyone socially you don’t live with or have a support bubble with in a private garden or at most outdoor public spaces, but on the other hand it goes on to say ‘However you can see friends and family you do not live with (or do not have a support bubble with) in some outdoor places, in a group of up to six’. Confused.com?  

Whilst the rules are set to allow more freedoms for families to mix between the 23rd and the 27th December, to do so is a dilemma that I think will challenge many people. I fear that just like the recent Thanksgiving celebrations in the US, unless people abide by the rules, Christmas will bring a third wave of community infections and once again our hospitals and primary care services will run the risk of being overwhelmed. None of my or J’s children or my 11 grandchildren form part of our ‘Support Bubble’. Faintly clandestine meetings at motorway service stations have been mentioned. But none of us really wants to do that. Shades of going to Barnard Castle spring to mind. Who to meet up with and where is a dilemma that I suspect many families up and down the land will be wrestling with.

Strangely, where to spend Christmas Day wasn’t always a problem for me. As a nurse and senior nursing officer, I would always spend much of Christmas Day at the hospital, visiting staff and patients alike. As my family grew, and I moved into general management, I stopped making these Christmas Day visits. Of course, there are many health and social care colleagues who will be away from their families over the Christmas periods. They will be working in the wards, care homes, A&E departments, in primary care and in the community. This year, the pandemic has meant that many of these staff are already exhausted and face the prospect of not having much rest or respite over the Christmas period.

When politicians and the media ‘shroud wave’ about the NHS being overwhelmed, it’s because there might not be enough staff to run the services. And there aren’t.  I live in the North West and every day there are around 11% of staff absent from work due to either being Covid positive, in isolation, suffering from stress-related mental health problems or some other health problems. That is 1,500 people not working. This compares to the ‘normal’ average absenteeism rate of about 4%. It’s true to say that the pandemic has brutally exposed the reality of the workforce issues facing health and social care services. Last week the informed, independent and research-based Health Foundation published a report by its REAL (research and economic analysis for the long term) Centre. The report was entitled Workforce Pressure Points (Building the NHS Nursing Workforce in England). You can find the whole report here. Be warned. It makes for a sobering read.

The report notes that even before the pandemic, workforce issues had increasingly become the biggest challenge for health and social care services. Nurses are the key group of workers where the shortage of staff has become critical. Just under half of all vacancies in the NHS are nursing posts. So we have a perfect storm of long term nurse shortages, exacerbated by Covid 19 absences, with those that are in post becoming increasingly exhausted and less resilient. There are also the negative and demotivating consequences of individual nurses once again being moved from their regular specialist areas to support the demands being faced by critical care services. Much research has shown that high workload (and the stress this brings) leads to feelings of not being able to provide the appropriate quality of care. It can quickly become a professional and personal dilemma that fuels nurse dissatisfaction and increases the risk of nurses leaving the profession.

If the demand for Covid-related critical care doesn’t lessen, I predict that much of the elective work that was restarted in the Autumn will once again cease. In turn reducing or stopping elective work will store up real problems for the future as waiting lists grow longer by the day. Causing harm to patients, past, present and in the future is not what the NHS is about – the reverse is true of course. When, or if, to take a decision to stop elective services in order to prevent the NHS from becoming overwhelmed is a dilemma that managers across the NHS are increasingly having to face.

The Health Foundation report charts the reasons for the shortage of nurses, most of which are probably well known. There are no quick and easy solutions, but I was struck by two of the issues that could be addressed immediately. The first was retention. Much more needs to be done to retain those nurses we already have. Measures to ensure staff wellbeing during the pandemic have resulted in some success, albeit this is increasingly becoming limited. More needs to be done with much greater investment required to effectively support and retain our nursing colleagues. Fair pay, proper access to supported continuing professional development, flexibility of working hours and a supportive working environment are just a few examples. The other issue was overseas recruitment. A national, ethical and properly resourced approach is required. If we don’t put such an approach in place, we will be guilty of simply applying an immoral sticking plaster. Both these approaches will cost money, and there are many choices as to how our scarce public money might be spent. It is, of course a live dilemma for our politicians to grapple with. I hope, like my children this Christmas, they choose to do the right thing.   

 

A Child in Time: Deep Purple and a Classical Gas

One of the things about being in love with the best person in the world is having to share the TV time. Whilst young J and I have similar tastes, it doesn’t always extend to our viewing choices. For example, I could watch ‘Come Dine With Me’ and ‘Four In A Bed’ every day. If I do, J retires to our music room and plays her piano, listens to music or reads one of her classic books. But we do occasionally watch the same TV programme. Last week it was a catch up version of the Netflix hit ‘The Queen’s Gambit’ – Episode Five really resonated.

It was the music in the soundtrack that caught my attention; part way through there was a slightly jazzed up version of ‘Classical Gas’. Older readers of this blog will perhaps remember this instrumental, young viewers have a listen (and watch this version played with consummate skill by Gabriella Quevedo) here. It was an instrumental piece written and first performed by the US guitarist Mason Williams in 1968. Personally, I think Gabriella’s version is far superior. There was another reason for the music catching my attention. Way back in 1976, I was on a student nurse placement at a day centre that specialised in psychodynamic interventions. It was one of the best placements of my nurse education. One year into my pre-registration education and training programme I fell in love with psychotherapy. 

Sadly, I never got to qualify as a psychotherapist. However, I did use psychotherapeutic approaches in my work as a mental health nurse, and much psychoanalytical theory underpinned many of my publications. I was aided in this regard by my long time writing collaborator, Professor Sue McAndrew, who is qualified. But I digress. On that placement I met a young man in his early 20s, who I shall call Ralph. He was withdrawn, angry and very difficult to engage with and smoked incessantly. He had long nicotine-stained fingers. Amazingly now looking back, at the time many mental health nurses smoked and one way of engaging with patients was to have a cigarette together. I was one of those nurses.

Ok, I cannot resist another slight digression. Many years ago, I would show extracts from the 1948 film ‘The Snake Pit’ to nursing students in Finland. These were Finnish students undertaking their entire nursing degree using only the English language. They were very bright, enthusiastic and a real pleasure to be with. It was a great film to take extracts from to show the cultural changes that have happened in both how we treat and care for people who experience mental health problems and societal attitudes to mental health and wellbeing. It’s still possible to buy a DVD of the film from Amazon. Almost all the healthcare professionals in the film smoked.   

OK, lets get back to the day centre in Swansea. I used to run a folk club in my spare time, and one day I brought in one of my guitars (the second one along in this picture). Upon Ralph’s arrival, he asked if he could play it. I said yes and after spending a bit of time tuning the guitar he started to play. Now I have been fortunate to hear live the supremacy of the Rolling Stones, the arrogance of Oasis, the stupidity of Clapton, the rock n’ roll of Chris Rea, the melancholy of Leonard Cohen, the surrealism of David Bowie, the lyricism of Bob Dylan and the creativity of Mark Knopfler, but in that moment they were all surpassed by Ralph – like Gabriella Quevedo, he played the guitar with supreme skill but also with an almost humble casualness.

He told me he had learnt to play in school. Playing music was one way he could escape into himself and away from the realities of his home life. I never found out what the realities of his home life were, and back then I would not have had the skills or knowledge to be able to respond therapeutically in any event. However, my interest in understanding the impact childhood abuse (in all its various forms) might have as the child becomes an adult was very much stimulated by that placement, and eventually Prof Sue and I did quite a lot of our research around child sexual abuse (CSA). Even with a great deal more awareness of the vulnerability of many children and young people, still today, one in five adults aged 18-74 have experienced at least one form of child abuse (emotional abuse, physical and/or sexual abuse) before the age of 16. That is a staggering 8.5 million people. Of these, some 3.1 million were victims of CSA before the age of 16, with a much higher prevalence rate for females than males. You can find out more here.

Last Friday was #PurpleWinter, an annual social media awareness-raising campaign that asks people to wear something purple and share photos of themselves in support of the need to spot, and stop CSA wherever this might occur. The campaign was started by the former football player David Lean, who played for Preston North End est. 1875. He was sexually abused by his trainer, Barry Bennell. What is important about raising awareness through the #PurpleWinter campaign was that David Lean didn’t report his abuse until he was an adult and then the authorities didn’t believe him or take action.  Which, I would argue, in itself is almost a form of abuse.

So, if a child does approach us and starts to talk about how they might have been abused, we should let the child tell their story in their own way and at their own pace. We should remain calm and demonstrate we are listening and believe what the child is saying. This can be difficult as the natural inclination will be to ask lots of questions. Above all we should find a way of reassuring and supporting the child, but absolutely report what has been disclosed. Early safeguarding intervention will always be better than dealing with mental health problems further down the line. As I write this blog, I wonder what became of Ralph and whether like the beautiful music he was able to play, he was able to find that inner peace also. I hope so. Me, despite many years of practice, I still cannot play Classical Gas all the way through.