Spring is the time for plans, projects, and for staying healthy*

This week I did consider writing my blog around the ‘news’ that Mr Potato Head has become ‘gender neutral’. But in the end, I thought that in the middle of a global pandemic there were probably more important things to worry about. And despite the pandemic, I have felt in a good place these last few weeks. Last week, for example, it really did feel like Spring was in the air. We had cold mornings that quickly became warm sunny days. 

The sunshine brought with it a real feel-good factor. So much so, that my long trousers have all been packed away and the shorts have once more come out. It has been wonderful to be outside in the fresh air and see the sudden awakening of the countryside, and the beautiful big buds on our trees and plants just waiting to burst into leaf. The meteorological start of Spring is of course tomorrow, 1st March. The astronomical start of Spring (the Spring Equinox) is March 20th this year when the day is exactly as long as the night. Thankfully, after that the days will start to get longer as we head towards Summer.

Last week also brought back memories of Spring 2020 and the start of the Covid19 pandemic. As I write this, we are just 26 days away from that first lockdown anniversary. I don’t think many of us back then would have thought we would still be dealing with the pandemic a year later. But slowly and surely, dealing with it, we certainly are. This current lockdown has been much harder for many folk than that first one. For those having to commute to work, days have started dark and have been dark before the journey home is started. The past few months have been cold, wet, and generally miserable, with nowhere to go to, eat out or mix with friends. At least last Spring and early Summer, we could all be outside in the warm sunshine. Even for those without a garden, there were plenty of green spaces to go to for exercise.

I think on a personal note, one of the reasons last week felt so good was that I had a very quiet week of meetings. Not that I mind work meetings of course, but there were long periods each day that were meeting free. Interestingly, three of the meetings I attended (and all were with different groups and organisations) had a focus on people’s wellbeing. One meeting discussed what steps we might need to take to start to get our full range of NHS services back on track. Top of the agenda was the acknowledgment that we couldn’t begin to do that, until we found effective ways of helping our staff recover and regain their energy, motivation, and their mojo once more.

For most people who have been directly involved in providing health and social care to our diverse communities, such recovery is likely to take some time. For some people, recovery may be a long while off and sadly some will not feel able to take that step back to a re-positioned normality and will leave the NHS. I was pleased to see the announcement last week of the setting up of 40 dedicated mental health hubs across the England. They will be modelled upon the successful Greater Manchester Resilience Hub. This was set up after the Manchester Arena attack in 2017 to help NHS staff who were traumatised by having to deal with the victims and survivors of the atrocity. Since that time and during the pandemic, the Manchester hub has helped over 4,200 people. One of the meetings last week brought into sharp relief the psychological harm and trauma that some colleagues had experienced over the last year. It was also good to hear that these colleagues were receiving help and support.  

Unfortunately, there are other staff who simply don’t seek or choose to access the help that is available. There is still a great deal of stigma over seeking formal help for a mental health problem. Health care professionals are often reluctant to take advantage of the help that is available, or feel it’s too difficult to do so. The mental health hubs will therefore take a more proactive approach so as to better ‘reach out’ to those who might be deemed at high risk of experiencing psychological harm. Clearly, those working in intensive care units, emergency care departments and Covid19 wards are likely to feature in these high risk groups. So, it was wonderful that in that third meeting last week I heard a very eminent, highly-respected, and experienced surgeon talk about his mental health problems. He told of the support he had received and his commitment to help ensure other colleagues struggling also seek and receive help.

The telling of his story also made me think about what else we might be able to do to improve the health and wellbeing of not just our health colleagues, but the wider population. Next week is the beginning of Spring, and on March 3rd, the UK Chancellor Rishi Sunak will set out his Spring Budget. Yesterday’s papers were full of stories either demanding that Sunak reward all health care workers with an across the board £2,000 pay rise or saying that Boris and Sunak are set to ignore the magnificent efforts of the NHS during the pandemic by not rewarding them at all. I think the truth may well be somewhere in between, but time will soon tell.

What I would be more interested in is whether Sunak is able to do something that will impact upon the social determinants of good health. An individual’s employment status, their income, and where they might live will almost certainly have a greater impact upon their health than having access to high quality health care. I hope some of the measures the Chancellor introduced during the pandemic will continue for a while longer yet. I’m sure that protecting people’s employment through the furlough scheme for example will reap both economic and health benefits in the longer term.

We should also remember that in many places across the UK, the NHS is the largest employer by far. You will have probably read of the 60% increase in nurse training applications this year. Partly driven I suspect, by a sense of wanting to be part of a caring profession, but also partly driven by the notion of gaining secure employment. Of course, the NHS also plays a significant part in maintaining and growing local economies through the goods and services it buys. NHS Trusts are truly anchor organisations in many communities. I hope as Spring arrives, and the lockdown begins to ease, that with Summer on the horizon, we can find many more ways to work together to create a better, healthier community in which to live.

PS – It’s great that Lady Gaga has got her dogs back, but what a shame she has to employ a dog walker. Exercise is one of the best ways to improve one’s mental health and wellbeing.  

*apologies to Leo Tolstoy      

Finding a different place for healthcare: its the future

I’m habitually beaten at University Challenge by my classically educated wife J. Sometimes I just sit in wonder as she plucks a seemingly obscure answer from somewhere deep in her mind. In fact, I have little understanding as to how her mind works. Last week, for example she sat outside watching the garden birds feeding. Coming in she posed the question – ‘Of course, the birds don’t know about the Covid19 pandemic, do they?’. It’s a metaphysical question, like, ‘why is there something rather than nothing?’, that is almost impossible to answer.

However, on one level there is a relevance to the question. Since 14^th December 2020, all poultry in the UK has been required by law to be kept indoors because of several outbreaks of avian disease, or bird flu as its more commonly known as. The order applies to all poultry keepers whether you have a few hens or 100,000. This was rather a blow to our small hen enterprise. Whilst we have a super building in which to house our hens (and goats) it is normally used only for them to sleep in, the rest of the time the hens and goats are free to roam outside. As the weeks rolled on with no sign of the lockdown restrictions being lifted, we became concerned that our lovely hens were suffering unknown harm. Taking things in hand, we decided we had to do something to give our hens a chance to see and feel the sunshine on their feathers and live their best life.

Under Paragraph 35 of the Defra Code of Practice for the welfare of laying hens, it is permissible to provide a ‘veranda’ or ‘winter garden’ attached to the main hen accommodation. We got straight onto our builders who came round, weighed up the job and quoted us £3,250 to build it. Hmm, we thought, let’s build it ourselves. We measured up, ordered the materials, and started to build what came to be called the ‘hen house extension’. We started work on it just as the weather turned for the worse. We had decided to use 4 inch square posts, as we wanted the building to be strong and last for many years. Each one (6 in total) needed to be set in concrete. Try digging 3 feet deep holes in ground that is frozen while the snow falls around you and the wind turns your ears, nose, and fingers blue! 

But we eventually succeeded and have been rewarded by seeing happy hens protected from their pandemic, and yet still able to enjoy fresh air and sunshine.

Sadly, seeing their obvious joy, it did make me think about all those living in care homes, who have been isolated and in lockdown for so long over the past year. As the vaccination and the current lockdown reduce the rate of infections, hopefully, we will soon be able to see and hug our loved ones once more. However, I think there is a related but longer term problem we need to consider.

Last week I took part in a Good Governance Institute webinar that looked at the recent White Paper on the proposed changes to the way the NHS in England is organised and how future services might be provided. To my mind it was horribly ‘acute hospital service’-centric. There was very little said about the contribution community services, primary health care or mental health services could make to improving the health and wellbeing of individuals and the communities they live in. Information about the so called ‘place-based care’ was both vague and hard to find.  I think this will increasingly become a problem for many folk.

In England some 25 million people live with a long term health condition (LTC). We know that LTCs are much more prevalent in people over the age of 60 than any other age group. Likewise, 50% of all GP appointments and 64% of all hospital outpatient appoints are for those folk living with a LTC. Perhaps more importantly, 70% of all hospital bed stays and 70% of health and care spend is for people with a LTC. The reality is that the more people than not, aged over 65, have two or more LTCs – many more of those aged 75 years or over, have three of more LTCs. This is a health problem of the same magnitude as we face with the pandemic.

I believe that as a society we ignore this problem at our peril. I don’t think that our acute hospitals are going to be able to return to the pre-pandemic levels of performance or capacity in the near future. The Covid19 demands for every increasing infection, prevention, and control measures, coupled with the unresolvable constraints of many hospital buildings will mean that the numbers of patients being seen will be considerably lower in number. Not a good thought. We need to do more to help those with a LTC to live the best life they can, and to do so without having to come into hospital for their care. This is why developing ‘place-based care’ will be so important in the future.

We know the number of people with non-Covid health conditions have been massively impacted by the restricted nature or unavailability of healthcare services. Sadly, this is likely to be the case for some time. Our NHS colleagues are exhausted, burnt out and in need of some time away from what has been an unceasing call on their skills, knowledge and experience. I find it almost impossible to believe that, in the traumatic health context brought about Covid19, colleagues will not have experienced some level of psychological harm. People are not like our hens. But we do need to find way to better protect them from the causes of harm, which are often as unseen and unknown as those faced by our hens.

One of the speakers at last week’s webinar was Dr Claire Fuller. She is a GP and the Integrated Care Service Lead and Interim Accountable Officer for Surrey Heartlands Clinical Commissioning Group. She was also a totally inspirational speaker. My take home message from her was the thought she had that: ‘the legislation [NHS White Paper] should not be the limit of our ambitions’ – in effect we know what the problems are and will continue to be unless we do something, so seize the time, and make a difference. It won’t be as easy as building a ‘hen house extension’ but it could be just as powerful in terms of helping others live a better, healthier and longer life.

Roses are Red, Violets are Blue, this is a Valentine’s Blog just for You

Do you celebrate Valentine’s Day? Apparently, in our house we do. I have been told we do, which means, in our house, we do. Valentine’s Day has been celebrated since the Middle Ages. During that time, it was believed that birds paired up in preparation for breeding. This is just one of the many explanations as to why Valentine’s Day has, since that time, been associated with declarations of love and romance. St Valentine (and there seems to be at least three of them) was a clergyman. Some say he was a priest, others a bishop. He was certainly keen on converting others to Christianity. On a visit to Rome, he was placed under house arrest for his beliefs. For younger readers of this blog, just think of it as an early form of our current rule about mandatory self-isolation. So currently, if you come into this country from many other countries then you will have to spend 10 days in self-isolation, at a cost of around £1,700. I’m not sure if Valentine had to pay for his home imprisonment, or whether Rome paid for his stay.

Whilst self-isolating, he was visited by Judge Asterius, a kind of third century test and trace operative. The Judge had a young daughter who was blind, and it is said that when asked to cure her, Valentine laid his hands on the child’s eyes and restored her sight. Sadly, this did little to endear him to the Roman Emperor, Claudius II, who had him imprisoned, tortured and killed in Rome, on February 14th, AD269 for his troubles. It is also said that while imprisoned, he sent a note to Asterius’s daughter signed ‘from your Valentine’ - another one of the many explanations as to why the day is associated with love.

But let’s leave St Valentine for a moment, as there are other interesting (well, for me at least) things to consider about the day.

Do you know where those lovely red roses you gave or received come from? Now I did, which is one of the reasons I don’t give red roses to anyone on Valentine’s day. Most of them come from either Kenya, or Columbia. Both of which are a long way from the UK. They are picked by people on very low wages, and who often live in very poor conditions. The same applies to the cocoa used to make those delicious chocolates given and received today. Much of it comes from Africa (Ghana and the Ivory Coast produce 75% of the worlds cocoa market). I’m not sure that Valentine’s Day is widely celebrated in Africa, and as for me, I don’t give chocolates either.

Apparently, we do celebrate Valentine’s Day in our house. I have been told we do, so we do.

The giving of flowers to those we love, is of course, a longstanding tradition. Flowers can convey a message. For example, ‘Roses are Red, Violets are Blue, you weren’t my first choice but…’ – it’s called floriography, or the language of flowers. It was Lady Mary Wortley Montague, who brought the notion of floriography to Europe. She probably wouldn’t have been able to do this now in our post-Brexit world. Lady Mary was famous for many things. Two come to mind: her support of women’s rights being one, but also the work she did in setting in place the foundations for eradicating smallpox. She introduced the concept of inoculation against the disease.

On her return to England, she faced an uphill battle to get her ideas accepted by the establishment. Although this was around 1720, the challenges she faced seem very familiar to me today. The medical community simply didn’t give her the time of day. She was, after all, not a doctor, nor even a scientist. As such she had nothing to offer. The concept of ‘experts by experience’ simply didn’t exist in those days. And she was a woman, and a female challenging the thinking of men was just an anathema. It was many decades later that Edward Jenner convinced both the politicians and the SAGE equivalent of the day, that vaccinating the entire population could be the way forward on dealing with the smallpox pandemic. A global vaccination programme was implemented. There hasn’t been a case for some 40 years now. It was a devasting global disease, with three out 10 people who became infected dying from it.

Sounds familiar, doesn’t it? Thankfully, the world has a Covid19 vaccine and we are well on our way and have made a great start on getting people vaccinated. There are exceptions of course. Canada has no natural vaccine production, so has to rely on imports from Europe. The European Union haven’t really got their act together and the vaccination programme is not going well across all the member states. Tanzania has refused to accept the vaccines as being safe and have no plans to vaccinate their population. Here in the UK, up to 49% of those from BAME communities are still reluctant to have the vaccination. There is much more work to be done before we can realistically realise the Hancock dream of living with Covid, as we do with flu.    

However, let’s get back to St Valentine. I hadn’t realised that saints are expected to continue to work in the afterlife. Apparently, they have a range of responsibilities as saints to keep a watchful eye on what’s going on here on earth. Valentine’s responsibilities are far ranging. He is the patron saint of beekeepers, and for those who live with epilepsy, those prone to fainting, and for keeping travellers safe. From a romantic point of view, he is also the patron saint of lovers, engaged couples and happy marriages.

He is also the patron saint of plagues.

As for today, yes, we will be celebrating Valentine’s Day in style – no roses or chocolates, but there will be plenty of smiles, bubbles, sparkly moments, happiness, and love, and for the meat eating half of this 'blissful union', a big fat juicy rump steak dinner. 

Reforming Me: moving from listening, to hearing and believing

There are two particular words that will bring a sense of dread to those who have worked in health and social care for more than 10 years – they are ‘NHS Reforms’ – more of which later. However, in yesterday’s papers, there were other words that might also bring a sense of dread to many – front and centre of the FT Weekend were the words ‘Parents fear post-Brexit immigration system will spell au revoir for au pairs’. It was a clever headline, and one that I think which gave a slight nod to the somewhat cliched idea of the au pair having a relationship with the man of the house. What I didn’t know was just how many folk employ an au pair. It is estimated that over 45,000 families in the UK rely on au pairs for affordable childcare. I have to say, I’ve never ever thought about getting an au pair, childcare was the responsibility of one of the parents, grandparents, or whatever childcare setting you could afford to put your child into. Usually, in my day at least, it was a combination of all three approaches.

EU free movement ended this year. As such, au pairs who are designated ‘skilled workers’, now need to earn the minimum salary of £20,480 to qualify for a working visa in the UK. The consequence for families, (most of whom on average pay £100 a week for an au pair) is that they need to now pay about £180 a week. That is £180 a week plus board and lodging to provide around 25 hours of childcare a week. Currently the average cost of 25 hours in a nursery is around £131 a week, and there is no risk of the husband having an affair with the au pair either. What I also didn’t know was many of those 45,000 families who use au pairs are also nurses, doctors, policeman and other key workers. As I don’t think the Home Office are likely to change their minds over this, these changes are one more challenge for already hard-pressed key workers to address.

Many of these same people have been left exhausted, anxious and, in many cases, facing psychological harm going forward. What must they have felt if, like me in search of today’s news, they logged onto the BBC News website to see the words ‘Government plans to reverse Cameron NHS Reforms’? The headline refers to the Andrew Lansley reforms implemented in 2012 under David Cameron’s coalition government. There is nothing worse for health care folk to hear than the NHS is yet to be reformed once more.

The new proposals have been quietly socialised over the past 12 months through various ‘consultations’. These consultations have always seemed to me to have been carefully worded, so as to give rise to the outcomes the authors wanted to achieve. It was the ‘other’ Times that shone a light on what these reforms were all about: ‘Ministers to seize control of the NHS’. It sounded like a side story to the military coup in Myanmar and just as dreadful. One of the proposals is that the Secretary of State for Health would regain control and responsibility for the NHS rather than, as is the case now, NHS England.

Now that sounds like a great idea doesn’t it? The new reforms would make it possible for the Secretary of State to change NHS priorities more often than at present, and give more direct orders to the good folk at NHS England. We have seen (and felt) the consequences of such an approach in this government’s handling of the pandemic. Alongside this, Clinical Commissioning Groups (CCGs) are set to go. They currently control some £85 billion of health spending, but often indulge in some of the most bureaucratic approaches ever witnessed – well at least outside of a Handforth Parish Council meeting that is.  However, CCGs are GP-led, and taking their power to commission healthcare services for their patients away doesn’t seem a particular great way of keeping them on board.

If I’m sounding a little pessimistic, I don’t mean to be. There are many important changes in these reforms. Taking the decision making power away from local councils over whether to put fluoride in drinking water or not is one such example. This would greatly help improve child dental health. Tackling obesity in more direct ways is another. Obesity has proven to be a major contributor to the many of the 110,000 deaths from Covid the UK has seen. The creation of statutory Integrated Care Systems and doing away with the requirements for competitive tendering will be key in ensuring we are able to build upon the best of the innovative ways of working to have come out of the pandemic. Collaboration is key. What the pandemic has shown, in so many ways, is that when local health and social care organisations come together to find workable solutions to new problems, they will succeed in ways that up to now might have been thought impossible.

There is a however, in all of this though. A cautionary note that au pairs and families who employ them will be very aware of. The idea of an au pair is that they become part of the family. This can give rise to boundary confusions (and I’m not just talking about affairs with husbands). On one hand they will witness all our odd habits and behaviours, probably see our arguments and disagreements over who left the lights on or the toilet seat up yet again. On the other hand, they are a valued and welcome member of the household, who is entrusted to look after our precious children. But they are a paid employee, a stranger whose co-operation, loyalty and discretion we are essentially paying for.

Where the arrangement works well is where each party learns not to just listen to what the other has to say, but hears what is said, and most importantly, believes what is being said. We have seen much erosion of trust during the pandemic. A loss of trust in our political leaders, in the science, and the transparency of commercial decision-making to name just a few. If the proposed reforms are to succeed, then we need not only to rebuild trust in these areas, but find ways of building and maintaining trust across the new organisation forms. To do that we have to listen, hear and believe what others are saying, and in so doing create a shared vision and purpose.