Nurses of the Future: working flexibly, to achieve a healthy work-life balance

On March 2021, 12 months into the Covid pandemic there were some 681,527 nurses on the Nursing and Midwifery Council (NMC) permanent register. This was a rise of nearly 12,000 new registrations than the year previously. University data shows an increase of 32% in the number of applications for nursing degree places. However, right now, there are still 38,000 nurse vacancies across the NHS.

The last year has shown just what a vital role the profession has played in treating and caring for large numbers of some of the sickest patients many nurses will ever see in their lifetime. These nurses were often there to provide care, and be with, those patients who due to the restrictions, were on their own at the end of their lives. Some 16 months on, addressing the staggeringly high number of patients now on a waiting list for treatment continues to add pressure to an already exhausted workforce. Looking after the wellbeing of our staff has to be our highest priority.

Of course, during the pandemic it wasn’t just nurses who made a difference. For example, whilst I do want to come back to nurses in moment, last week I heard stories of the contribution cleaners made to keeping everyone safe. Many a time they were to be found undertaking deep cleans of clinical areas throughout the night. Managers too, often worked 14 hour days, 7 days a week keeping services going. There was a small army of volunteers, many who were retired health and care workers, but there were many folk too, who came to stand shoulder to shoulder with others in dealing with the challenges of the pandemic. 

Some interesting things emerged from addressing these challenges. Decision making became faster, agile working was introduced, and there was a step change in collaboration and partnership working. Technology came into its own, compassionate leadership came to the fore, and innovation was encouraged and fostered. Whilst there was a high degree of necessary flexibility in all areas to be seen, it was the commitment and sheer hard work of so many people that prevented the NHS from falling over. It certainly wasn’t political leadership that made a difference.  Sadly, no one back in March 2020 could have imagined that over a year later we would still be in a world challenged by the virus.  

Back to nurses. Last week I read the story of Gemma Dobson. In 2017, she was dismissed from her job as a community nurse by North Cumbria Integrated Care NHS Foundation Trust. The reason for her dismissal appears rather sad. The Trust had introduced a requirement for community nurses to work flexibly, which included working some weekends. Gemma found she couldn’t do so because of childcare commitments. Gemma had previously worked fixed shifts to make it easier to care for her 3 children, 2 of which have disabilities. Following her dismissal, Gemma took her case to an Employment Tribunal claiming unfair dismissal and indirect sex discrimination. She lost her case.

Last week, an Employment Appeal Tribunal took a look at the original decision to reject her claim of unfair dismissal, and found in her favour. I found the outcome very interesting, (you can read the full judgement here) and it has many implications for the future. The appeal tribunal found that Employment Tribunals must, in the future, where appropriate, take into account ‘childcare disparity’ into account when making a decision over unfair dismissal claims. Importantly, this ruling recognised that many women still bear a disproportionate responsibility for childcare than men. As such, women should not be penalised if they are unable to work flexibly because of these responsibilities. Gemma’s case will now go back to the Employment Tribunal for a reconsideration of her claim of unfair dismissal and indirect sex discrimination.

In fairness, I should perhaps point out that the North Cumbria Integrated Care NHS Foundation Trust was only formed in 2019, from two other hospitals coming together. I don’t know which of these Gemma worked for. Her case predates the formation of the current Trust. 

However, leaving the important judgement about ‘childcare disparity’ to one side, I do find it strange that there appeared to be so little recognition on the part of the Trust, over flexible working. Cumbria is a beautiful place; indeed, I was there yesterday walking in the hills. Although it may be beautiful, it can be an expensive place to live, and many parts of Cumbria are geographically remote. I imagine, (and of course I might be very wrong) that recruiting health care professionals could be very difficult.

Prior to the pandemic, other big employers like Tesco, Sainsburys and so on recognised the value of recruiting staff on a highly flexible basis, with hours that suited individuals. Many parts of the NHS have been slow to do so. The pandemic has shown us that as we transform future ways of working and providing health care, we need to also think more seriously about how employment practices might facilitate these changes. That said, I was heartened by reading on the North Cumbria Integrated Care web site, their absolute commitment to ‘reshape our workforce using innovative models, and value our staff by being a great place to work and embedding the right culture’. This is how we will ensure a healthy work-life balance is achieved, and happy staff mean happy patients.

A public inconvenience: the provision of future health care services

One of my favourite pieces of art from one of my favourite living artists is a piece called ‘Who’s chairing this meeting’. Urpu Sellar is this favourite artist; originally from Finland, she now lives and works in Scotland. I have probably the largest collection of her work, and if I had another room in the house, I would buy more. Each piece she creates gets its name from a play on words, and she is very clever as well as being very creative. A few years ago, I saw the chair in her workshop during a Spring Fling event (where artists open up their studios to the public over a weekend), and it was very much ‘work in progress’. I asked if I could buy it when it was completed and although she agreed, she didn’t know when she would finish it as her husband was living with cancer and her focus was on caring for him.  

I was surprised when about nine months later she phoned me and said that she had finally finished it, and if I wanted, she could bring it to me – at that time I also had a house in Scotland. We arranged a time and one evening, she and her husband brought it across. Her husband’s condition was not improving. He had just finished another round of cancer treatment in Edinburgh, which was a 200 mile round trip. Although it must have been tough, he had no complaints about making the journey, as that was where the cancer specialist worked. Despite his having more or less given up drinking alcohol, he asked if he could join me in having a small whisky. It wasn’t a problem for me, I am always happy to share a glass or two of whisky with anyone, particularly if they know their whiskies.  

Urpu later told me that he stayed in bed all the next day, but he had really enjoyed having the drink, the conversation, and doing something that wasn’t cancer-focused. He continued to travel to Edinburgh for his treatment, but sadly died a few months later. Whilst I no longer have the house in Scotland, Urpu has remained a good friend. Every time I see the chair, with its 62 little birds on it, I am reminded of that evening together.

Last week the ‘Who’s chairing this meeting’ chair came into my mind for similar reasons. The week was jammed packed with meetings, although that is not unusual. One of these was an interview panel for a new Consultant in Acute Medicine. I have been used to chairing such panels in my previous Trust and was expecting to do so with this panel. The Divisional Director had other ideas and assumed the Chair. I didn’t mind and certainly was not going to have the discussion about it in front of others. I’m seeing her next week and I’m sure we will have a conversation about what happens next time. It’s often the case that the Chair sets the tone for the meeting and helps keep people engaged or conversely, and more easily, allows people to become disengaged with the discussion.

A couple of my meetings last week were concerned with exploring the progress being made with folk who continue to find themselves on waiting lists. There are currently more than 5.2 million people in England on waiting lists. Of these 385,000 have been waiting for over a year. Where I live there are 450 folk in every 100,000 waiting for over a year. Where I work, one in eight people are waiting for their treatment. The age of particular populations is a factor in the number of people on waiting lists. Some of the areas across England with the highest numbers of those waiting have the oldest populations. Those with the lowest rates also have the youngest populations and these are folk who are less likely to require hospital treatment.

Age is also important for other reasons too. Last week I heard tales of the many folk who simply won’t go somewhere else for their diagnostic assessment or their treatment, preferring to wait until a place becomes available at their local hospital. Some of the reasons for these choices are perhaps more understandable than others. Like many NHS services, we are using the independent sector to enable those most in need to have their operation. It seems that a number of the older patients offered this service don’t want to take up their place because they need to have their bowel preparation done before they pitch up at the hospital for their operation.  I can understand the anxiety this might cause. It’s the same kind of anxiety that has kept many older folk isolated because so many public toilets have been closed as a consequence of the pandemic. Speaking from experience, when you need to go, you need to go.

Other reasons are more difficult to understand. Simply not wanting to travel somewhere to get your health care seems inexplicable to me. Unlike Urpu’s husband, who was prepared to travel hundreds of miles to get his treatment, some of our patients simply don’t want to receive their treatment unless it’s from their local hospital. I think if I were faced with a possible life-shortening illness, I would want to get my diagnostics and treatment where I could, and get it done in the quickest possible time.

Like many places across England, Greater Manchester has developed a ‘waiting well’ approach to help patients who find themselves on a long waiting list. I think it is a great initiative. Not only does it help keep patients in touch with the progress of their referral, but it also provides an opportunity to promote healthier life choices. Communicating with patients is particularly important as many folk, understandably perhaps, are going to their GPs to ask how their care is being progressed. The unintended consequence of this is a huge rise in people seeking an appointment with their GP. Not getting one quickly enough, they then pitch up at the Emergency Department to get an answer. Likewise, the ‘waiting well’ approach also allows for proactive discussions to be had over alternative ways that they could receive their care – including day case care, or receiving their care at a different location.

My sense is that this is a conversation we will increasingly need to be having as place-based services are developed. Helping communities and neighbourhoods to better help themselves, addressing inequalities, and tackling the underlying social determinants that give rise to poor health and wellbeing is clearly a way of avoiding long waiting lists in the future. This is how we might effectively ‘build back better’ and create a post pandemic world where I don’t have to chair so many meetings and more importantly, folk don’t need to travel 200 miles to get their treatment.

Children that care, and cared for children

I was looking something up the other day and came across this extraordinary phrase - ‘binary arguments are the crack cocaine of human interactions’.  They can certainly shut down conversations, cause division, anger, and huge upset amongst families, communities, work colleagues and friends. Think about Brexit, or climate change, or even who you might vote for at the next election. However, it needn’t always be such big issues that give rise to binary arguments. For example, in our house we have a night owl and a morning lark that share the same bed.

I naturally wake up early every morning and I’m raring to go. On the other hand, J can stay up way past my bedtime and still be cheerful, productive and on the go. Yes, occasionally I will have a slower start to my day or stay up to watch something on TV, and likewise J will set her alarm and get up early if we go off out for a walk. But essentially we are stuck in these binary positions of being an owl and a lark. And we are not alone. Actually that sounds a bit weird. What I mean is that there are plenty of others out there in the same situation.

Last week I read a report of a large study undertaken by researchers at the University of Exeter involving just short of 500,000 people. The report suggested that if you are a natural early riser, then you are likely to be happier and be protected against depression. The study worked out who was a natural early riser by looking at their genes – ‘larks’ genes tend to be slightly different from those of night owls. ‘Larks’ thrive when they get up early and go to bed at a sensible time and they are likely to do so 7 days a week. Night owls on the other hand defy their natural body clocks by getting up earlier than they might want to for work and so on, and are more likely to ‘sleep in’ at the weekends. Binary opposites like this in relationships are usually thought to make it difficult to coexist. Happily, we do!

In our house, it’s not just sleep that provides example of such binary opposites. Food is another area. We both love food. I love shopping for food, cooking and eating food, as does J (well she likes the eating bit). I’m a vegetarian and J is an omnivore. Like sleeping, we manage to co-exist okay. And of course, there are possibly good and bad aspect of both diets. Recent US studies have shown that eating a vegetarian diet can help prevent heart disease, cancer, obesity and even reduce the risk of developing severe Covid19.  The reduction in risk compared to meat eaters can be as much as 59%. However, researchers at University College London and Great Ormond Street Institute for Child Health have found that children who are given a vegan diet are likely to grow up shorter and have weaker bones. Their research notes that vegan children (now that also sounds weird) should be given daily vitamin B12 and vitamin D supplements, so as to avoid potentially long term health issues. There are said to be over 600,000 people in the UK who eat a vegan diet, and if you want to join them, there is some helpful advice here. For ideological reasons, I have been a vegetarian since my late teens but these days, I’m always willing to buy meat and fish for J. I draw the line at cooking it for her, however.

Children were also on my mind last week for other reasons. I was thinking about ‘children who are looked after’, and ‘looked after children’. Two very different groups, yet two groups who share many similarities. They are all children and young people who care for or who are cared for. Today marks the end of this year’s Carers’ Week. This is a week where the importance of unpaid carers in many people’s everyday lives is recognised and acknowledged. You can read about this year’s campaign and news here. Carers of all ages often face many challenges. However, children and young people who are carers face some of the most difficult. The Children’s Society has a web site (see here) that sets out in big, bold and no uncertain terms what some of these challenges are.

The sheer scale of the numbers of children looking after someone else is staggering. The Children’s Society estimate there are over 800,000 young carers aged between five and 17 who are looking after an adult or other family member in the UK. ‘Looking after’ in this context will often mean providing care for someone who has a physical or mental health problem, or someone, perhaps because of drug or alcohol misuse, is unable to appropriately care for themselves. Caring for someone with such needs brings with it huge disruption to the normal processes of maturity, education and socialisation. Sadly, it is often true that young carers are hidden from view, with their caring responsibilities simply not known by other significant adults or even their friends. So, finding ways to promote resilience and properly support them can be difficult.

The other side to this binary position is those children and young people who are ‘looked after’. The term ‘looked after’ has a specific and legal meaning that is set out in the Children’s Act (1989). In March this year, there were 107,163 children and young people being looked after and in care in the UK. Children (up to 30% of children in care enter the care system before they are four years old) and young people come into the care of a Local Authority because it is either unsafe for them to remain in their home or because, for many different reasons, their parents are unable to look after them. Like young carers, ‘looked after children’ can experience the same disruption to their education and in accessing opportunities to grow and learn. Whilst many of these young people have good experiences, it’s still the case that many care-experienced adults struggle to find employment compared to their non-looked after peers.

There is currently an Independent Review of Children’s Social Care which is due to report in Summer this year. I hope that by the time we get to Carers’ Week 2022, we will have started to see some significant improvements in how all our children and young people are cared for in our society. For me, it's not just the care of the individual that counts the most, its the care of relationships all children and young people experience that really matters. This, I hope, is not a binary argument to make.

Celebrating the return of Lost Labours Loved

There are two things I remember best about last week and they are connected by the word honorificabiltuinitatibus*. I will leave you to work out why, but here is a clue. One was hearing the first cuckoo of the year and the other was our celebration of Volunteers’ Week, more of which later. That cuckoo? Last Sunday J and I were walking up Clough Pike, (a great Lancashire walk and one I would recommend doing for the spectacular views, if you are ever up here) when we heard the distinctive call of a cuckoo. It is unmistakeable. Nevertheless, J pulled out her phone, turned on her ‘Identify that Bird’ app, and took a quick recording. A short while later, and the app duly reported that it was 100% sure it was indeed the Common Cuckoo. Now I’m not sure we needed the app, but J is on a steep learning curve when it comes to identifying birds by their song. The problem with doing this is that you have to stop when you hear a bird singing, record their song and wait for the analysis to come through. Often the bird, whose song you have heard, stops singing just as your try to record it. Some of our walks can be like travelling on the M6 on a Bank Holiday Monday, stop, start, take a few steps, stop, start and so on. Not that I mind, I love J and I love being outside walking and try to do so as much as possible.

Walking and being outside always feels like a good use of my time. I think when I walk, I exercise when I walk, and get to see many new places in different ways when I walk. I like the fact that when we get lost on our walks (which frequently happens), it’s not seen as a waste of our time, but just more steps.

I met a group of other people last week who use their spare time in a different way. I was privileged to be part of our hospital Volunteers’ Week celebrations on Friday and was very glad to be. The celebration event marked the contribution that 21 volunteers had made to our patients’ experience, the life of the hospital and to the communities we serve. Collectively, they had been volunteering for an incredible 140 years! Due to social distancing, the 21 volunteers represented a much larger group of volunteers who have all given the incredible gift of time to help others in so many different ways.

I had been given citations for each volunteer, which I turned into a ‘This is Your Life’ type presentation for each person (younger readers of this blog ask your parents about the ‘big red book’). It was great fun and there was much laughter, smiles and even a tear or two. We had scones (cream or jam first depending on your personal preference) and a warming cuppa, and for a while we could forget about the challenges of the past 15 months.

Many of the volunteers had to stay away from the hospital as the pandemic took hold and restrictions and shielding became necessary. Friday marked the beginning of a return to the hospital for some of these volunteers. They can’t as yet go onto the wards, but have started to become ‘guides’ once more for patients, relatives and visitors to the hospital. Given the many corridors, confusing signposting and natural anxiety that many folk have when coming into hospital, this is a vital service. And if you can’t remember which of the many car parks you have parked your car in, they will happily help you find it too.

Whilst locally the pandemic brought about a reduction in the number of volunteers at the hospital, nationally, there was a huge response in the numbers of people who wanted to give some of their time to help those unable to help themselves during the lockdown. In March last year, the Secretary of State for Health and Social Care went on TV to ask for some 250,000 people to become volunteers to help the NHS. The response was overwhelming. Some 750,000 people came forward during the first pandemic lockdown. They picked up prescriptions, phoned those who may have been struggling with loneliness, collected and delivered shopping, and completed a myriad of other acts of kindness. During the early months of the pandemic some 10 million people provided help to others by volunteering. A survey undertaken by Legal and General in May 2020, calculated that the time given by this army of volunteers was estimated to have the equivalent economic value of more than £350 million a week.

Volunteers have taken on new roles as the response to the pandemic changed. Our politicians may claim the credit for the successful vaccination programme, but the reality is it would have been nowhere without the efforts of the many volunteers who acted as guides, marshals, and clerical and administrative staff. It has often been the volunteers, who at a neighbourhood level have helped overcome vaccination hesitancy. Likewise, our GPs stepped up and converted practice and health centres into mini vaccination hubs, staffed and supported by volunteers, often retired doctors and nurses too.

But it’s not just the response to the immediacy of need that has been so impressive. Many of those volunteers who responded to Matt Hancock’s call have stayed around. I think it may well be what they found in those early days of volunteering. The loneliness, anxiety, frailty, poverty and other vulnerabilities they will have encountered weren’t caused by the pandemic. The social determinants that resulted in these outcomes have been known for a long time and sadly have not been addressed. We are still awaiting the publication of the ‘oven-ready plan’ for tackling the issues of social care, and the pandemic has certainly brought these into sharp relief.

Whilst last Friday we were celebrating the many years of volunteering that people had gifted to the hospital, what I find very encouraging is that there is now a new breed of volunteer. They are the so-called millennials. Folk aged between 20 and 30. They were the group least likely to volunteer. When they did so however, they gave the most time - up to 4 hours a week, sometimes much more. This bodes well for the future of volunteering, and the impact volunteers have in so many ways on so many peoples’ lives. We lost the labours that so many loved to give in helping others before the pandemic, but we are slowly finding new ways that volunteers can continue to once more be there with and help others. That’s something to celebrate indeed!

*its literal meaning is ‘a state of being able to receive honours’  - I use it tweaked to mean ‘you deserve to be honoured’ – it appears in Shakespeare’s play ‘Love Labours Lost’, which also features both an Owl and a Cuckoo