Trauma informed practice: caring for our patients, and our colleagues

Until the middle of last week, I don’t think I had ever heard of the little French town of Crepy-en-Valois. This small town is situated just 40 miles outside of Paris. It has a population of around 15,000 people. Having lived in a small town before, I know such towns can be a little like the metaphorical Peyton Place (if you were born after 1969, ask you parents what this means). It was J who brought this small town to my attention. She taught English (as part of her French degree) there from 1989 and still has friends made there on social media. Last week, the Crepy Facebook site posted that they were closing their Covid vaccination centre due to having run out of supplies, and wanting to conserve the remaining stock so as to give the second vaccination as per Pfizer and World Health Organisation guidelines.  

Of course, the supply of vaccines was much in the news last week. It worries me, and I know from many of the meetings I attended last week, other people are concerned too. Many of those people are senior NHS managers and leaders. However, it wasn’t the supply of vaccines that rose to the surface of my mind when I was thinking about this week’s blog. It was something else, that came from reading up on that little French town. And it was something I had forgotten all about.

In 1982, the second deadliest road accident in France’s history occurred. The deadliest was of course, the terrorist lorry attack in 2006 on Bastille Day in Nice. That night 86 people were killed and some 458 were injured after a lorry was deliberately driven at them by Mohamed Lahouairj-Bouhel. The 1982 road accident saw 55 people lose their lives, 46 of whom were young children. All were from Crepy-en-Valois. Most died from a fire that engulfed the coach in which they were travelling, and from which they were unable to escape.

It was a tragedy that was almost incomprehensible. Reading the story once more I was reminded of the Aberfan disaster in Wales in 1966, which I have never forgotten. Then 116 children were killed by a huge landslide of colliery spoil. It is certain that such communities don’t easily recover from the trauma of such a catastrophic and sudden loss of so many children’s lives at once. The unexpected loss of anyone is sad, but I think the loss of a child’s life will always be particularly difficult.

The suffering of children was also something of a focus in a couple of the meetings I was in last week. Whilst the UK has one of the highest Covid death rates per million of population, children’s deaths from Covid are very rare and have primarily occurred where the child has a serious underlying health problem. We know from much research that children are much less likely to become infected and if they do, are more likely to have less severe symptoms. However, it is the harm that children may be experiencing as a consequence of the restrictions and political decisions taken to deal with the pandemic that concerns me, and I’m sure many others too.

I attended a safeguarding meeting last week, where the number of children found to be at risk was almost 50% higher than in the previous year. There are other reports of the risks children have been facing as a result of schools being closed. In Ofsted’s annual report, published last December, they noted that teachers were often the first to be able to spot signs of abuse or neglect. Staying at home has meant many children became invisible to teachers and other trusted adults, and as such may well have suffered unseen abuse and neglect. Prior to the pandemic, about 20% of safeguarding notifications came from schools and early year settings. Sadly, for some children, schools provide the only respite they get from the abuse they experience at home.

The pandemic has left many of these children with nowhere to go to escape the trauma of abuse. Childline, the children’ charity helpline, has seen a threefold increase in the number of counselling sessions focussed upon child sexual abuse with the family. Some children said that as a consequence of having to spend more time with their abuser, they had been sexually abused more often during the [first] lockdown. The NSPCC has reported that it has seen a rise of 23% since the pandemic started of calls from adults worried about sex abuse occurring in the home. A number of the reports from children - about a quarter of the calls to Childline - were about abuse that happened recently, and a further 20% talked about abuse that had been going on for at least a year. Unsurprisingly, but very concerning nevertheless, were the calls from children and young people who were spending more time on their own; not having contact with friends meant that they experienced distressing memories of previous abuse. About a third of callers talked about sexual abuse that had occurred over a year ago, and for some children and young people this was the first time they had told anyone about it. These are the ‘hidden harms’ of the pandemic.

Whilst the evidence shows that with the right support, at the right time, children and young people can recover after experiencing the trauma of sexual abuse, some survivors of childhood sexual abuse do not get this support and expert help. In such cases, the impact of abuse in earlier life will be there and can manifest itself in many different way during a person’s life (see here for examples). In the context of the pandemic that worries me. The Office for National Statistics notes that 1 in 4 women and 1 in 6 men have experienced some form of abuse before they were 16 years old. These are statistics, but they are also the people we may well be working alongside each day. I worry as the trauma that many health and social care workers are experiencing in dealing with the pandemic now is, in itself, a retraumatising environment and context.

My last meeting of the week was one where I joined other Non-Executive Directors to explore our duty of care to colleagues working in our health and care services. It was a very interesting and important debate – and there was much acknowledgement of the importance of embracing a trauma-informed approach to both the care of our patients and those with whom we work. If you don’t know what that is, you can find out more here – and whether it’s a Crepy-en-Valois coach crash, Aberfan disaster, child sex abuse or the Covid pandemic we might be facing in the future, we should all strive to build a trauma-informed society (and in the case of the NHS) a trauma-informed workforce.

Every vaccination lights another candle against the darkness; the complexity of pandemic ethics

Last week we heard that Glastonbury is to be cancelled for a second year running. I’m not surprised, and I don’t suppose many others would have been either. It must have been a very difficult choice to make. Indeed, according to Michael and his daughter Emily (Eavis), they have tried every which way to keep it a possibility, but to no avail. Going to Glastonbury has long been on my bucket list of things to do before I die (more of which later). It is one of the iconic festivals that I have yet to get to, and I have in my time, been to many. I was a teenager in the 1970s and enjoyed many a Summer of Love at a variety of famous music festivals, all of which, for me, at least, were illicit-drug-free experiences. Glastonbury has always been one of the first festivals to take place each summer and over the years has become increasingly complex to arrange and set up.

Whilst the next Glastonbury festival is now planned for the Summer of 2022 (and all the weekend long tickets have been sold) I am still hoping that some music festivals will happen later this year. However, as I was thinking about what initially felt like a lost opportunity to do something that I had wanted to do for a long time, it made me reflect on what I now think is really important. The Covid pandemic has possibly made lots of other folk also think about what has really become important in their lives.

It was this pause for reflection that led me to thinking about whether I still had a bucket list of things I still wanted to do. Apparently, it was one Justin Zackham, a British screen writer, who is credited with first using the term ‘bucket list’. He wrote the screen play for the 2007 film The Bucket List, in which two terminally ill men decide to try and do all the things they have written down on a ‘what to do before I die list’. It’s a great film and if you haven’t seen it, you can download it from Amazon (and other streaming services). Be warned, you may need to have a box of tissues handy in places. Trust me when one of the men (Edward) meets his granddaughter (who he didn’t know he had) for the first time and crosses off ‘kiss the most beautiful girl in the world’ from his bucket list, you will be reaching for the tissues.  

Much of the film is about the different places in the world they have wanted to travel to and see. Travel to far flung places is often a point of friction in our house. I have been fortunate through my time working at the university to have travelled all over the world, whereas J has not been able to afford to do so and would dearly love to. These days the idea of travel, particularly long distance travel, holds absolutely no appeal for me. Travel does not appear on my ‘bucket list’ at all apart from a promised postponed honeymoon to the Holy Land. I’m sure J and I will find a way to accommodate both our ambitions. But of course, the choices we make over whether to travel or not are relatively straightforward and will eventually be resolved through a comprise.

As we were able to see last week, in health care, making the right choice can be a difficult thing to do. There was a challenging example of this in the assertion by Lord Sumption, a former Supreme Court Justice, that he did not accept that ‘all lives are of equal value’. To say this sparked controversy would be an understatement. At a time when many healthcare professionals are increasingly faced with making decisions as to who might receive critical care, I’m not sure starting a public debate on ethical decision making in this way was totally appropriate.

Dear reader, please don’t misunderstand me. I think ethics, and in particular healthcare ethics, are more important now than they have ever been. The pandemic has brought into clear view what I think is one of the most difficult aspects of our current political, organisational, and everyday clinical decision making. Ethical decision making should be about doing what is right and good for the greatest number of people (within resources) but knowing what that might be is extremely complex.  

Last week I had my Covid vaccination. It was simple, painless and TBH, brought me great relief. I was vaccinated as part of the vaccination programme at one of the hospitals I’m a Non-Executive Director at. Thankfully the hospital vaccination hub has almost completed vaccinating all of my colleagues there, as well as nearly all those people living in our local community who are aged over 80 years of age. I’m not, by any stretch of the imagination, a front line member of staff. Due to my age and the recommendation made by NHS England/Improvement, I shouldn’t really be eligible for my vaccination until the end of February. My hospital, like many others I suspect, who are delivering the Pfizer vaccine, are making best use of the rather unreliable available supplies to get as many people through the door and vaccinated as possible. As my #earlyrisersclub friend Deb noted: ‘every vaccination lights another candle against the darkness’. Getting my vaccination made me feel grateful, but also guilty.

I would rather have given my place to my wife J, who is not destined to get her first jab until the end of April. On the basis of doing the most good to the greatest number of people, personally, I would have liked to have seen the vaccine go to all those working in keyworker roles: teachers, policeman, nurses, bus drivers, doctors, fireman, ambulance workers, supermarket staff and so on, first. Without them being available to keep the rest of us safe, cared for, warm and protected, society as we know it would probably grind to a halt under the pressures of the pandemic. Politics rather than science prevailed and a different priority vaccination programme was put in place. 

It is our children and young people who will feel the impact of the pandemic more than any other group in society. Protecting their future health and wellbeing is crucial. Acquiring and maintaining reasonable health (and I know what you are going to ask, what does reasonable mean?) is the precondition to successful engagement in society and human flourishing. If you want to know more, why not get hold of a copy of Norman Daniels’ book: ‘Just Health, meeting health needs fairly’. Like the film Bucket List, it was also published in 2007. There are no easy answers to ensuring we are all ethically sound in our decision making and the choices we make in helping others. The last words go to Michael and Emily who suggest: ‘one thing last year taught us is that fundamentally we all need human connection’. Whatever decisions and choices we are faced with making, now and in the future, let’s try and make sure we keep this thought in mind. When communicating and connecting with others, kindness matters. 

In appreciation of the ‘Lurking Therapists’

Over the last 10 months, I have often said a big THANK YOU to all those people who keep us safe, well, cared for, warm and fed, able to get where we need to be and who make sure our rubbish is collected week in week out. Then there is that often unacknowledged group of people who regularly deliver all those letters and parcels to our front door. However, every time I do so, I feel an equal measure of guilt (that I’m not doing enough) and pride in all those who are unselfishly reporting for work day after day and just getting on with things. Whilst some might think lockdown restrictions are hard, getting up every morning to leave your house and go to work is tougher still. You might also think that simply saying thank you is an easy thing to do.  At one level of course it is. We can all stand at our front door on a Thursday night and clap for our heroes, but are we sure what this actually might mean? I don’t know Annemarie Plas - the person who ‘borrowed’ the idea from Spain and Italy. I have nothing against her, but her promotion of this gesture of gratitude raises a number of questions for me. It is the ‘why, what, where and how’ of appreciation.

In March 2020 I eventually struggled with the first part of the question, the why was I doing this? I increasingly felt it was somehow expectant upon us. If someone didn’t see me out there on the pavement at 8pm on a Thursday, would they think ill of me? Whilst I was (and still am) genuinely appreciative of all that those working in the NHS and all care services continue to do for others, I found the sense of obligation to demonstrate this appreciation simply felt wrong.

I was also aware that there were a large group of people in the NHS who did not appreciate this public show of gratitude. I think it is often easy to assume that gratitude will always be a positive thing for those in receipt of it. This time around I have not gone outside and clapped. I’ve now found other ways to say thank you and show my appreciation. I believe that kindness matters, and simply saying thank you whenever and however you can, is one way of expressing your gratitude to those whose kindness to others makes such a difference.

For me, last week was most definitely another week where THANK YOUs were in order, and there were so many occasions when this was the case. Some were frivolous but also very welcome. For example, my eldest daughter Facetimed to show me the snow that had fallen that day. She lives in Leeds and they had plenty of snow, whereas on the same day we only had rain. And plenty of it too. Seeing my daughter’s house and garden covered in snow was lovely, particularly as we haven’t really had any. But it was the joy in my grandchildren’s eyes as they described how much they had enjoyed being outside in the snow that was really warming – simple delights, but so important.

Perhaps more importantly was the closing down of Trump’s social media accounts; long overdue and the ensuing silence has been golden. His impeachment must come a close second in terms of good news stories from across the water.

Closer to home, I was very thankful that my parents, who live in Wales, finally got their Covid19 vaccination. Despite what was being reported in the media about the difficulties those is Wales were experiencing in gaining access to the vaccine, the system did eventually come good for my parents. They were thankful, and just a tad proud, to have received it.

And I have to confess to also being a tad proud of colleagues last week. It was a group of wonderful folk who were doing amazing things with their colleagues working at Blackpool Teaching Hospitals. Last Wednesday, I met them at a meeting for those providing psychological support to colleagues, which I had been invited to attend. Although I was there wearing my Board Wellbeing Guardian hat, I have to say it felt a real privilege to be part of their conversations. It was in part a peer-supervision session, as well as an opportunity to exchange concerns and ideas. It would be inappropriate to share the content of their conversations, but there were a number of things I heard that made me thankful these folk were doing what they were doing. I even learnt a new term – ‘therapeutic lurking’. This was a description applied to an approach where these psychologists literally lurked in various clinical environments in order to have conversations with staff working there as these arose naturally. There was no mention of mental health, or any of the terms associated with mental health problems, such as anxiety or depression for example. It was about just being there offering support in ways that meant something for the individual or team.

I also took away a couple of challenges to think about and in time, to try and so something about. One of these was about one particular clinical team who were described as a ‘well-oiled machine’ where everyone knew what their part was and delivered this well. On hearing this description, I wondered what they did with their emotions. Much has been written about the emotional labour of health work. It was the sociologist Arlie Hochschild who described emotional labour involving the use of, or suppression of, feelings in order to sustain an outward appearance that produces in others a sense of being cared for in a safe and knowledgeable way. It is also a defense mechanism against stress. However, at times in health and social care, it can work against health and care professionals being truly therapeutically connected to those they are caring for. And for some people, it can be a difficult place to be, both at work and when the day’s work is finished.

My last vote of thanks goes to my Non-Executive Director colleagues, who last Friday were there for me. There was nothing therapeutic about the situation, which doesn’t need retelling here, although I did feel cared for. I don’t think any of them actually read my blog, but that doesn’t stop me from saying a big THANK YOU to them for reaching out when I most needed them. 

Looking through the window of hope: A better post-Covid19 world beckons

Most readers of this blog will not remember the Window Tax. Probably because it was first introduced in the UK in 1696 and then repealed in 1851. It was a tax that was deeply disliked, but all houses with more than 10 windows had to pay it. Sounds like a lot of windows doesn’t it? Having counted ours, and we live in a normal (some might say quirky) average sized house, we have 34 windows. That doesn’t take into account the conservatory (or Sunshine Room as we like to call it). In today’s money, having this many windows would cost us £168 a year if the Window Tax was still in force, which I have to say would be a lot cheaper than today’s Council Tax!

Back then it was the landlord who was responsible for paying the tax. A responsibility that was passed on to tenants in higher rents. Often resentment at having to pay the tax resulted in windows being bricked up or, in new buildings, simply not putting in sufficient numbers of windows. In 1766, the tax was extended to include houses with seven or more windows. The result was the number of houses with exactly seven windows reduced by 60%. The Window Tax was a forerunner of the equally unfair and unpopular Poll Tax. Readers under the age of 30 might need to ask their parents about the Poll Tax, but suffice to say there was rioting on the streets at its introduction.

For many people, there were often dreadful population health consequences of the Window Tax. Living in houses without sufficient light and ventilation, resulted in large numbers of people becoming high risk victims of epidemics such as smallpox, cholera and typhoid. It was a harmful and unfair tax for the poor to bear. It was said to be a tax on health, fresh air and light.

Now you might be wondering where this trip back in history is taking you. Well fast forward to 2021 and here we are, in the throes still of a pandemic more virulent than cholera, typhoid, and possibly smallpox too. The World Health Organisation (WHO) estimate that 120,000 people a year die from cholera, 140,000 from typhoid, and until its eradication in 1980, smallpox had killed some 300 million people during the 20th century. At 04.30 CET this morning, the WHO were reporting 1,906,606 deaths of people from Covid19 (and that is yesterdays figure and only those officially reported to them). Later on today you will find up-dates here. Hopefully the various Covid19 vaccines will enable the world to more effectively deal with the disease.

However, whilst we also have a vaccine for smallpox, the world still has little herd immunity to that disease. While not wishing to be a scaremonger, two WHO-approved laboratories still hold the last remaining stocks of smallpox; one laboratory is in Russia, the other in the US. Personally, I can’t think of two more worse places for storing such a lethal virus. Well OK, I guess North Korea…

But back to that tax on health, fresh air and light. Last week I read the wonderful story of Dr Fresh Air. Dr Fresh Air (real name Eilir Hughes) is a GP working in North Wales. He has long been a campaigner for adding the word ‘replace’ to the more familiar ‘hands, space, face’ slogan. Dr Fresh Air believes that replacing stale air in a room with fresh air from outside reduces immensely the risk of people becoming infected with the Covid19 virus. We have all become accustomed to washing our hands (more often than before), and maintaining the 2m social distancing spaces between each other. Mask wearing has become almost ubiquitous (unless you are someone famous, a politician, plain stupid or all three). However, as our understanding of Covid19 has grown, a new risk has become apparent – that of the tiny virus particles (known as aerosols) lingering in the air.

The now famous South Korean study showed emphatically that the virus can travel and infect others much further afield than the 2m social distancing safe space recommended. Sadly, these days many buildings are constructed with windows that don’t open. It’s not just offices, but apartments who rely on air-conditioning rather than having windows that might be opened. Whilst air-conditioning itself is safe, the way it moves air around in an unventilated room is a problem. The South Korean study showed how the air flow from the air-conditioning moved the virus particles around the restaurant, leaving a discernible pathway of infections in its wake. I have to say one of the things I have missed most about the lockdowns and the Tier restrictions has been not being able to go out to eat. However, in following the science, I’m now glad I haven’t been able to eat out. Truly ‘eating in’ has become the new ‘eating out’ as far as we are concerned in this house.

Opening a window and allowing fresh air in can significantly help reduce this risk of infection. However, not only are we in the throes of a pandemic, but we are in the middle of Winter, and it’s cold. Leaving a window open all day is not something many of us probably fancy doing. Indeed, in the weeks leading up to Christmas last year, we had builders in the house for 3 weeks. They had a daily routine. Arriving around 8.15, they would turn on the radio, boil a kettle (unusually, they brought all their own tea-making essentials) and opened every window and door in the ground floor of the house. Usually by 8.30, I was both fed up with listening to Wave Radio and freezing cold – and don’t get me started about the dust.

By the time they left at 3pm, I would be like the proverbial block of ice, and looked like a Michelin Man with all the added jumpers I had put on during the day. Our builders knew that as well as social distancing and mask wearing, fresh air and good ventilation were essential to keeping us and them safe. We don’t have to go to the same extremes as our builders to reduce our risk of infection. Opening windows once or twice a day is probably just as good and saves on the amount of the thermal underwear you might need to wear.

And in the strange way these things sometime happen, yesterday we received a long letter of apology from our window suppliers. They were saying sorry for the delays in getting our replacement windows to us and fitted. We ordered them in late September last year, but Covid19 had severely impacted upon their suppliers. Whichever way you look at it (or in the case of windows, through it), Covid19 has and continues to, impact upon all our lives. But there is good news. We now have a vaccine and increasing numbers of people are being vaccinated, and our new windows are now due to be fitted next week. As Confucius almost said, we may live in a small and quirky house, but our windows look out on a very large world, a world full of hope.

Like the transience of snowfall, Covid19 will eventually pass and warmer, brighter days will return

There is something almost magical about waking up to find it has snowed overnight. When I lived just outside Manchester, looking out of the window and seeing the snow-covered vista was always wonderful. Albeit, I knew that I would have a couple of hours work to dig myself out of our 500-yard long drive before I could get to the road. Having moved to the Fylde coast a couple of years ago, one of the things we have both missed is waking up to a snow-covered landscape. In the week leading up to Christmas, it seemed everywhere around us had snow except us. Then, like some kind of Christmas miracle, on the very last day of 2020, I looked out of the bedroom window to see it had snowed, just enough to cover the ground and turn everything sparkling white. It was beautiful, but sadly the snow didn’t last long.

Of course, snow wasn’t the only thing I missed during 2020. Being with people, doing ordinary things together would come high up on my list. There is something special about being in the company of others that is difficult to replicate using Teams or Zoom; although I sense that in the future many people will be reluctant to return to ‘the office’ full time. As might be expected, I will not miss the pain, sorrow, misery and harm Covid-19 brought to so many during 2020. Unexpectedly perhaps, the pandemic did bring into clear view the important role we all have in keeping ourselves and others safe. It wasn’t just the scientists, nurses, doctors and carers we recognised, but the bus drivers, shop workers, refuse collectors, schoolteachers and faith leaders who we finally rightly acknowledged as being essential and key workers too. We clapped them all for the vital work they continued to do, and despaired that such resilience and determination wasn’t matched in the actions of our inconsistent (and some might say, incompetent) political leaders.

One of my New Year’s resolutions was to once again try and steer clear of politics in my blogs, so please forgive me when I say that I find it hard to celebrate Brexit. I shall miss the freedoms and opportunities that being part of the European community has allowed me to enjoy for most of my adult life. In a world where increasingly, we have come to depend on each other for so much, ‘sovereignty’ seems such a redundant concept. Whilst I may not be able to look forward and see a bright and rosy future for the UK outside of the EU, on the third day of this new year, I do believe 2021 will bring with it many opportunities to do things differently and to really make a difference to others in so many ways.

I think seizing these opportunities and addressing the challenges is going to require a different kind of leader. For many years I have written about the importance of transcendental leadership, which has sometimes been called servant leadership. Servant leaders give to others; they don’t take. They put the interests of others above their own, and encourage flexibility, creativity and innovation in the people who work with them. They don’t just think about people being an organisation’s greatest resource, but recognise that people are the organisation. In a world which can increasingly feel very precarious in so many ways, (staying employed, having somewhere to live and food on the table), servant leaders work to ensure stability, confidence and help people gain a sense of making a contribution to a cause that is larger than the job they might do.

Whilst the pandemic has shown us that many traditional jobs and ways of working will fall by the wayside, developing newer roles and different ways of working will be critical in repositioning our normal. It’s not just individuals who might need to find a new career pathway, whole organisations need to as well. The NHS is leading the way in showing how, in the public sector, more collaboration can provide greater benefits to a wider number of people and their communities than continuing as individual organisations trying to be all things to everyone. It simply is not sustainable, economically possible or even desirable. Working together to tackle inequalities is the most effective way to ensure good health and wellbeing are experienced by all.

Another kind of sustainability grew in people’s awareness as the pandemic challenged the beliefs we had about the predictable physical and social world we inhabit. The inextricable links between our ‘taken for granted’ global travels, the desire for ever more cheaper foods, with favourite varieties being available all the year round, have driven large-scale agriculture, deforestation, climate change and global warming. The impact of the choices we have made, (and continue to make) will see even more damage being done to our planet. However, there are literally green shoots of changing behaviours, consumer preferences and political commitment. Whether these will be enough remains to be seen. As the Director General of the World Health Organisation, Tedros Adhanom Ghebreysus said recently, ‘there is no vaccine for poverty, hunger, climate change or inequality’.

Whilst the Government has a critical role in improving population health (see here), there is always going to be an interdependent relationship between the health of the individual and the health of the wider population. See here for a wonderful example of this in the story of Tolu from this paper published some 13 years ago. Interestingly, (well for me at least) the paper also cites the work of Amartya Sen, the economist and philosopher. He noted that health represents both functioning (that already achieved) and capability (the achievable). Health, therefore, is a means to realising an individual’s ambitions and personal goals as well as an end in itself. 

Covid-19 has exposed our vulnerability as a human race to something neither contemplated nor encountered before on such a scale. And it’s not going away any time soon. Indeed, as I write this, the early morning news is full of the impact the new Covid variant, Christmas and the increasing shortage of health and care professionals is having on our ability to manage the pandemic. Whilst I believe there is a brighter future for us all, I also believe right now the best we can do is to live within the various Tier rules, accept the vaccine when called and look out for those around us who may be struggling. Like the transience of snowfall, Covid19 will eventually pass and warmer, brighter days will return.