Have you Ever Given any thought to the winds of change blowing around the NHS?

There was a lot of change heralded last week. A new radio soap opera was launched. It’s called ‘Greenborne’. It tells the stories of everyday folk as they learn to live in a post pandemic life. You can listen to it on local radio stations – see here. I don’t think it will dislodge the dominant Archers, which for 70 years has told the stories of everyday country folk, but who knows?

I do know that I’m a man who likes nothing better than getting my shorts on, whatever the weather. Last week an opportunity to change the way I might free my legs emerged – the skirt. Apparently skirts for men are the new thing and have been included in the recent fashion collections of Stefan Cooke, Burberry, Ludovic de Saint Senen (names that don’t mean anything to me, sorry). Covid and working from home has revolutionised the male dress code (suit top, pyjama bottoms). As we emerge from our home offices once more, is the world ready for skirt-wearing men? I think J’s clothes are quite safe, although she does have a very attractive black tartan skirt in her wardrobe, so who knows?

I didn’t quite know what to make of Charles Walker’s speech in the House of Commons last week. I do like all things surreal, but his speech took surrealism to a new level. It was a rather strange protest parody on the price of milk (which we never did find out whether it was too high or not). He stated that in the remaining days of the lockdown, his protest would be symbolised by him walking around everywhere with a pint of milk. Will such surrealism change the voice of politics in the UK, who knows?

We do know that the captain of the stuck container carrier, the Ever Given, in the Suez Canal isn’t Marwa Elselehdar, Egypt’s first female sea captain. Almost immediately it happened social media lit up with the speculation that it must have been her steering the ship. The everyday sexism on social media continues to dismay me. It’s sad, not amusing and I was glad to see others point this out as well. I do feel for the actual and, as yet, unnamed captain. It must feel like that he is living a nightmare almost as big as his ship. We also know that the impact on world trade has been equally enormous, and is likely to continue to be so for some time. Will the work to free the ship and Monday’s big tide be enough to refloat her? – nobody knows.

The Ever Given story absolutely illustrates how vulnerable and exposed world trade is to something as simple as a twitch from Mother Nature. Reading the story, I was astounded by the sheer amount and variety of goods that are transported around the world in this way. I guess, like many others, I have taken for granted that if you can afford it, it’s easy to get whatever you want from wherever you want.

How many of us took full advantage of Amazon’s amazing ‘keyboard to doorstep’ delivery of everything we needed (or thought we did) during the darkest days of the pandemic. I know I certainly did. The parcels kept coming almost relentlessly. In fact, sales soared by some 51% during the pandemic, and Amazon delivered some 1.5 billion packages worldwide. That is a lot of cardboard, perhaps a discussion for another blog, but if you are interested in what this might mean for all of us, have a look here. I know I’m glad we get our own eggs from our own hens.

Amazon was also in the news last week for other reasons. The company announced that it would be expanding its virtual healthcare service (Amazon Care) to all its US employees, and they could have it for free. This is a service that offers virtual visits, as well as face to face primary care visits in the person’s home or place of work. Amazon Care can also send a health care professional to the person’s home for blood tests and other general assessments. It’s an on-demand service that allows people to connect to a doctor via chat or video conference for a consultation. Amazingly in just a few minutes.

Now I don’t know about you, but when I ring my GP surgery for an appointment, it can take many minutes (12 at my last try) to get to the head of the queue, and then I have to listen for a further 2 min 45 seconds of messages and disclaimers, before I connect to someone, not a doctor or practice nurse. They usually tell me they don’t have any appointment slots. Interestingly Amazon have been successfully trialling their service now for some 18 months. Whilst it will be free to Amazon employees (a huge benefit in the US), they plan to offer the Amazon Care service to other companies for a fee. I suspect that this might just be the first dipping of the proverbial toe into the US health care market, a market worth $3 trillion a year. Could we see something like this in the UK, who knows?

Twenty years ago, Tim Newburn and Richard Sparks, in discussing political cultures noted that ‘what happens in the US today will happen in the UK tomorrow’. So, it’s a possibility. Look at the success of Babylon Health UK. In a world where so many of us seek information, make decisions, and communicate using our phones, an effective online, on-demand access to health care service would be the next logical step. During the pandemic, we saw out-patient and GP appointments successfully carried out via video links, we have seen the establishment of virtual Covid wards in the community, and much greater use of data. Even the much maligned Test and Trace service has shown the power of using information differently (albeit at a huge cost).   

There were two other aspects to what Amazon were trying to do that resonated with me and I think reflected the ambitions for change as set out in the recent NHS White Paper. Amazon intends to focus its efforts on the home as a place where care is given. It also wants to reduce the individual and societal burden of disease by improving primary care and health promotion and prevention. I don’t know about you, but these are ambitions I would also like to see realised. Do we need Amazon to help make this happen, who knows, but I think not? 

Brief Encounters of the NHS Kind

Do you remember the suave Dr Alec Harvey? If you are under the age of 70 you probably don’t. I will reveal the answer later, promise. He was an enigma. He was also a rascal, although ultimately, he was a gentleman. He was an idealistic GP, who also practiced one day week as a Consultant in an acute hospital. Last week I also heard he was possibly a great example of a doctor who knew about public health practice as well as someone who treats whatever is presented in front of him/her.

There is something in this thought. Most of our clinical colleagues are educated, trained, and prepared to deal with whatever medical problem is presented. Many do so with great skill, knowledge, and leadership. However, and I didn't know this, you can actually train to become a Public Health practitioner (enabling you to be qualified as a Public Health Consultant) with  or without a medical degree. I think this training and education might equip students with different leadership skills than those found in most doctors. Don’t get me wrong, I think we need doctors and other clinical staff with both sets of skills and knowledge. However, as demand for health care continues to grow, partly driven by ever increasing numbers of people living with long term and complex health needs and partly because of the pandemic legacy of untreated conditions, I wonder if the NHS will have enough resources to meet all these demands. I fear not.

Last week it was agreed that the NHS will receive an additional £6.6 billion to help pay for the additional costs of Covid and the recovery of the elective programme of treatments and care. Although the longer term funding of the NHS still needs to be resolved, this is welcome news indeed. In addition, an extra £341 million has been provided for adult social care services – most of which will help ensure infection prevention and control measures are maintained. You can read the details of these additional payments here.

Welcome as these additional resources are, I think the NHS is still left with a longer-term funding issue. Very few cost improvement savings will have been made last year. Many hospitals have underlying financial deficits (often many millions of pounds) that have been largely hidden from sight by the command and control pandemic funding flows – but they are still there. In addition, the NHS has  a ‘backlog maintenance’ bill of some £9 billion, which is almost as much as it costs to run the NHS estates each year, which includes heating and lighting buildings, feeding patients, keeping hospitals clean and so on. Backlog maintenance costs are calculated on what would be required to restore a building to its optimum level of functioning. Strangely, it does not include or reflect any planned maintenance work. Many hospital and community services suffer from buildings that struggle to meet today’s accommodation standards. The pandemic revealed the difficulties many hospitals had in ensuring adequate ventilation for example.   

Given the impact of the pandemic on the UK’s economic resilience, I find it hard to believe that these are issues that might be easily solved through some type of austerity programme, although I‘m sure we will see a return to a fairly long period of economic austerity in the years to come. The UK spends just over £3,000 per person on healthcare each year. The current total funding of the NHS is £130 billion, which will rise to £136bn by 2022. That is a lot of money.

I wondered what you might spend that kind of money on to solve some of the world’s wicked problems. One of the first things to pop up in my search was an advertisement for a book entitled ‘How to Spend $75 Billion to make the World a Better place’. I have not read the book so cannot vouch for its veracity, but you get a flavour of the sort of things you could do with a fraction of that kind of money. I also wondered, if I were Prime Minister, what would I do or how might I spend the money to make the NHS a better place too? I think it would have to be spent on tackling the social determinants that promote or inhibit good health and wellbeing.

Some 40 years ago now, another famous GP, Dr Julian Tudor-Hart published a paper in The Lancet that discussed the issue of the inverse care law. He was a pioneering research-based GP, very much into preventive approaches to medical practice, and using data to underpin policy development. His inverse care law describes the somewhat perverse relationship between the need for health care and its actual uptake. He suggested that those who most needed medical care are least likely to receive it. Conversely, those with least need of health care will tend to use health services more and probably do so more effectively.

His work has been built upon by many other researchers and clinicians. I think his voice is not heard as often and as loudly as it should be these days. Public health has become the metaphorical Cinderella in a pandemic-dominated world. However, there are some who are doing things that might provide a clue to possible ways forward. For example, one of the stories I read last week was one citing the outrage at the London Mayor Sadiq Khan’s recent air pollution initiative. This is the so called Ultra Low Emissions Zone (ULEZ) charge (£12.50 a day) levied on older vehicles entering the London congestion zone. According to Living Streets, the UK school run produces the same amount of carbon emissions as Greenland each year. The ULEZ initiative is calculated to save the NHS £5 billion and prevent over one million hospital admissions over the next 30 years. Now that is foresight that should be applauded. It’s also a great example of the dilemma facing many in public health in taking forward policies that will make a difference, will save money, but will only do so over time.

The outrage directed at Sadiq Khan’s initiative is that he is drives around in a £300,000 Range Rover. You perhaps need to read the full story to judge whether you think this outrage is appropriate. I don’t. And if you want to consider buying a similar Range Rover to Sadiq’s, you can find the details here.  

Oh, that other famous GP, Dr Alec Harvey? He perhaps is even more famous than Dr Tudor-Hart. He was the doctor in the 1945 film of passion, romance, suicidality, trains and tea rooms that we know and love called ‘Brief Encounter’.

Moral Injury and ‘Is what I’ve done good enough?’

You might be relieved to see that this blog is 100% Harry and Meghan free, although TRIGGER WARNING, there will be a mention of bed pans. But for the moment I wanted to talk about the #caring4ourNHSpeople webinar I attended last week.  I think these are really great little webinars and you can find more information about them here. Last week, the webinar featured Professor Neil Greenberg. What an interesting person he is. His day job is a consultant occupational and forensic psychiatrist who is also a fabulous researcher. Before moving to King’s College London, he served in the armed forces for some 23 years. He is well qualified and experienced in treating psychological trauma, and since 1997 has been the ‘go to’ authority on the development of peer-led traumatic stress support packages. His work will resonate with many of us as we look to find ways to support colleagues through the pandemic. I love his title – Professor of Defence – perhaps revealing his psychoanalytical leanings - but what a great title for a doctor who has served in the military for so long.

His talk looked at many things, the notion of moral injury was one element I thought was particularly interesting. It’s not an illness in itself, but can leave you vulnerable to stress and other mental health difficulties. Moral injury occurs when something we might normally take in our stride becomes something that becomes so fixed in our thinking that it starts to interfere with our normal functioning. So, for example, we all have possibly been in the situation where we wonder if we did the right thing, could we have done more to save someone perhaps? At the heart of moral injury is the thought that I did my best, but it just wasn’t ‘good enough’. I imagine that there will be many health and social care colleagues who over the past 12 months will have experienced those feelings. Professor Greenberg’s suggestions for how we prevent moral injury and or deal with the impact of it were surprisingly (and refreshingly) non medicalised. This didn’t mean that if someone developed a mental illness that they shouldn’t seek skilled help and treatment, clearly if that is what is needed, then we should do all we can to make sure such help is available.

We know that many people who might benefit from such help and treatment often don’t access it. So, I liked his description of metaphorically putting your arm around someone who might have such needs and guiding them to those who could help them. However, there was much that he advocated that many of us, with very little training, could use to effectively support others. Supportive, but regular conversations with colleagues, end of shift reviews (not psychological debriefings), buddying up with colleagues for each shift, and watchful waiting. There was something else that I liked, an approach called PIES (nothing to do with cheese and onion or meat pies) which very much resonated with how I think psychological support can best be provided. You can find out more about these approaches here.

However, Professor Greenberg’s talk also made want to think about something else that was on my mind last week. I had been taxed with the question of what makes for an effective partnership and how would I approach creating these. It’s an interesting question, and again a question that challenges the zeitgeist landscape envisaged in the recent NHS White Paper. Almost  13 years ago now, I undertook a large-scale piece of research that looked at trying to explicate the role of partnerships (what they had to offer, what was important and how to make them effective) in changing the health and wellbeing of local communities. This work led to the development of a conceptual model, that also drew upon the Winnicott's psychotherapeutic notion of being ‘good enough’. The ‘good enough’ partnership model is made up of eight elements. 

Now then, back in 2009  (when I first started posting my blogs) I was in that school of thought that subscribed to the ‘why use 10 words to explain something, when 1,000 words might be better’ (J has now educated me otherwise).  As a consequence, it took 3 volumes to explain these elements in full. Don’t worry dear reader I’m not going to try and work my way through them here, but as I reflected upon this work, I thought how much of what I had written then is still germane today.

We should only develop partnerships for the ‘right reasons’. There should be a shared vision of what might be possible, what the long term focus of the partnership might be. In the context of the NHS White Paper, I hope it’s to reduce health and other inequalities. The proposed partnerships will be ‘formalised’ as the legalisation is taken through parliament. However, there are ‘high stakes’ involved in this process. Effective partnerships can’t be simply prescribed and legislated for. Partners must have a compelling reason to become part of a partnership. This will mean having the ‘right people’ involved. Identifying and facilitating the involvement of all the appropriate stakeholders needs careful handling in order to avoid having too little views around the table, or too many that might cause more conflict than collaboration.

Achieving this will necessitate having the ‘right leadership’ available. I’m sure this might be functional, personality-based in approach or simply a combination of all of these, to be used at different times and in different contexts. Great leadership will promote ‘strong well-balanced relationships’. Such relationships don’t just happen. They need to be nurtured, managed, and supported in order to create better interdependent working. This is not going to happen in the absence of ‘trust and respect’. Trust and respect are absolutely about demonstrating how the espoused (and hopefully shared) organisational values are enacted. I say hopefully shared because ‘good communication’ will be critical. Learning to listen to what’s being said, not just the words, but the message too. This is sometimes more difficult to do than say.

And Bed pans? Last week I was asked the question ‘did I know how they got to where they needed to be?’ by my youngest daughter. She has this knack of asking such metaphysical questions. She has just started her first placement on the NHS Graduate Management Scheme. Last Wednesday she spent the entire day pushing trolleys around a very large acute Trust delivering bed pans to the wards and departments. She ended the day with very sore feet (daft shoes) feeling very tired, but also very happy too. She understood the message of what she had been doing. Bed pans are essential if you need one. Getting them to the right place at the right time was all about effective partnership working between clinical and non-clinical colleagues. I think that on Wednesday, she definitely became the ‘good enough’ partner.

Wisdom or Shame: deciding the future of the NHS

When did you last read the Rime of the Ancient Mariner? Up till last Friday it was some 50 odd years ago since I did. My beautiful well-read wife J had never read it until last Friday evening when we read it together. Even if you haven’t read it, I’m sure most readers will be familiar with some of its lines. The most well-known is likely to be ‘water, water everywhere, nor a drop to drink’. We were prompted to take a look by my telling J of a story I had seen earlier in the week about an albatross named Wisdom. Aged 70, she is the ‘oldest known wild bird in history’. Wisdom is a female Laysan albatross, and on the first of February she hatched her 37th chick. Reading the story, I was struck by a number of things.

For example, the word albatross is often used (at least metaphorically) to mean a psychological burden that feels like a curse – more of which later.  

I also wondered about the amazing scientific curiosity of the ornithologist and biologist Chandler Robbins who first banded Wisdom in 1956. She outlived him; he died in 2017. I marvelled at the longitudinal study he started and which still continues to this day. This scientific patience and endurance is all the more important given albatrosses only breed once in every two years.  

Despite the fact that Spring has once again brought with it the welcome sound of birdsong in the morning, it seems we need every new chick we can get these days. The RSPB have reported that there are 40 million birds fewer now in the UK than there were back in the 70’s. In the US, bird numbers are down by nearly 3 billion birds. Climate change and disappearing habitat are thought to be the prime reasons for this decline in bird numbers. I read last week that coffee drinkers might be guilty of contributing to both the disappearing habitats and the decline in birds.

For hundreds of years coffee was cultivated in countries such as Brazil (and many other South American countries), and Africa under the canopy of mature trees. This coffee was often referred to as ‘shade coffee’. The tree canopies provided a brilliantly health-giving habitat for many species of birds, some of which migrate each to the UK. But when was the last time you heard a cuckoo call?

Since 1970 coffee production has developed more sun-tolerant coffee plants, which can be planted in higher-density open spaces created by felling the trees. The situation throws up a dilemma for coffee drinkers, economists, and environmentalists alike. Many of the world’s coffee producers participate in global schemes aimed at supporting developing economies. However, modern coffee production is still damaging our planet. But where would many of us be without that first cup of coffee in the morning? Speaking from experience it’s better to keep a low profile until that first coffee is consumed. You can buy ‘shade coffee’ from the RSPB online shop, see here.

Coffee wasn’t the only focus of dilemmas I heard about last week. Another was around the future provision of comprehensive healthcare. It is unlikely that, in the short to medium term, we will be able to restore health and care services to their former pre-pandemic levels. Dealing with the Covid19 pandemic brought many healthcare professionals face-to-face with stark choices about who should receive what care and where. When I say stark, I mean literally who might receive life-saving treatment and care and who might not. At both the hospitals I’m involved in clinical ethics committees were set up to provide a forum for such difficult decision-making. Thankfully, whilst the NHS creaked under the weight of Covid infections, it wasn’t overwhelmed and mercifully, such decisions were few and far between. Other countries have not been so fortunate.

I imagine that many doctors faced with such decisions might well have seen their knowledge, experience, and skills as being, like that Ancient Mariner’s albatross, a curse rather than a blessing. Given the devastation of the UK economy caused by the costs of dealing with the pandemic, I think we as a society are likely to be facing equally challenging decisions over who gets what treatment, where and by whom. In my discussions last week, we were challenged to undertake a slightly Netflix version of the famous Bernard Williams challenge of deciding who Jim would choose to kill to save the lives of 19 others – see here. The choices we were given included killing the wealthiest, the oldest, the person with cognitive challenges, anyone but the women and children. In the event the majority of the participants chose to kill off the oldest person. I won’t say who I voted for, but interestingly, in the UK it was the oldest in our society that we chose to protect first from the devastation of Covid19.

The older members of our society were those that were seen to be most vulnerable. The pandemic revealed the extent of inequality across the UK. Whilst this was helpful, it’s important to remember that the world didn’t start on 31st Jan 2020, when the virus arrived in the UK. We have known about the social determinants that impact on population health and wellbeing for many, many decades. The NHS itself was set up to address social injustice and health inequalities. Yet here we are nearly 73 years later and many of these issues have still not been tackled. The Budget last week didn’t mention social care, or the growing needs of those living longer with complex and long-term conditions.

Unlike the Ancient Mariner’s colleagues whose decision-making was based upon superstition, ill-founded beliefs and the need to scapegoat, those commissioning, funding, and providing health and social care services will need to rely upon good public health data and evidence to underpin decisions over future service provision. Making this data and analysis transparent will lead to new concepts of reasonableness in future decision-making. This is not an easy task. The erosion of trust in our politicians, in the popular understanding of science and in our sense of communitarianism has been enormous. However, we need to find a way of restoring this trust and quickly. Failure to do so will lead to us health and social care professionals being condemned to wear an albatross of shame around our necks, because we will have let this and future generations down. If we get it right, however, we can look forward with hope that like the Wedding Guest in Coleridge’s tale who patiently listened to the Ancient Mariner story and ‘a sadder and a wiser man… ...rose the morrow morn’.