Freedom Day: a Pyrrhic tale

It’s not every day that you come face to face with your future. More of which later. First, have you ever heard of Ptolemy? You may not have done to be honest; he was born in 367 BC and can trace his ancestors back to Hercules. He believed the earth was the centre of the universe and that the sun, moon and other planets revolved around it. My writing companion and I wrote a paper way back in 2007 that used this notion to explore how patients could be used in nurse education – ‘Passive patient or engaged expert? Using a Ptolemaic approach to enhance mental health nurse education and practice’. Ptolemy was also influential in helping his mate Pyrrhus regain his throne in 297 BC. Pyrrhus became king of Epirus (a mountainous region in Greece) at the age of 13, but was dethroned just 4 years later. Like Ptolemy, Pyrrhus was a fierce opponent of Rome and the Romans, and fought many battles against them. One of his most famous was the Battle of Asculum. However, any celebration of winning this battle was short lived and misplaced due to the thousands of lives lost. It was a military shambles and gave rise to the term a Pyrrhic victory.

I remembered this story last Monday when our so called ‘Freedom Day’ arrived. The Prime Minister who had, up until fairly recently, been crowing about how we were finally to be free from over a year of Covid restrictions quietly changed his tone and message. Monday 19th July became a somewhat Pyrrhic victory in our Government’s battle against the pandemic. As we now know, the day was marred by soaring rates of Covid infections, many thousands (millions actually) forced into isolation because of their contact with someone who had tested positive, food shortages in some supermarkets and totally incomprehensible Government guidance. It was no wonder that the Prime Minister abandoned has planned Churchillian victory speech.

I was just pleased that at the 11th hour we got some sensible and very clear advice from our colleagues in Public Health England over keeping the Covid restrictions in place in all health care settings. It remains to be seen how easy that will be to maintain. Over the past few weeks there have been increasing numbers of patients and visitors who have stopped wearing masks while in the hospital grounds. There were many reports of younger adults getting out and about, as dancing and drinking together was back on the cards. They appear to be the largest group of folk in the population with vaccine hesitancy. It also remains to be seen what impact this will have on infection rates, hospital admissions and deaths.

Last Thursday J and I experienced for ourselves what Covid restriction-free life could be like. We were attending the wedding of one of my nieces near the beautiful town of Frome. They had chosen a stunning place to have the ceremony and celebrations. Orchardleigh is a 500 acre estate with a wonderful stately home at its heart – see here. We were a bit nervous about going there and mixing with the other wedding guests, and upon our arrival kept to mask wearing and socially distancing. It was a relatively small wedding with just some 40 guests and it soon became evident that most had no intention of adhering to any sensible precautions. At first it felt difficult and uncomfortable.

The ceremony was held outside in a large walled patio, and although we found ourselves sitting close to each other, the sunshine and fresh air were somewhat reassuring. The celebrations after were also partly outside, only going inside for the dinner. The room had tall ceilings with each table well-spaced from the next. The sunshine and heat meant that all the outside-facing doors were left wide open. The day and evening turned out to be much less stressful that perhaps we had anticipated, and it was so wonderful to see some of my family in the flesh once again. I don’t know if it was the early start - I was up at 4am so we could travel down and avoid the worst of the traffic - the sunshine, or those couple of glasses of wine I had, but goodness I slept well.

On the map, it looked as if we were fairly close to Cardiff, where my parents live. That being the case we thought we might nip across country and pay them a surprise visit. It was a two-hour journey mainly on small country roads, although crossing the River Severn on the new Prince of Wales bridge was brilliant. We did eventually arrive, and my Mum and Dad were surprised and pleased to see us. Like many other older folk, the loneliness that came as a consequence of the lockdowns and so on has been hard to bear. Both my parents are now in their 90s and my mother has mobility problems that mean she often spends many hours each day sitting in an armchair. She can no longer really tend her garden, which was a big passion of hers, and seldom travels out of the house. My father is more able and will go out to do shopping and so on, but is looking frail and vulnerable. He spoke of the increasing difficulties he has in simply managing the everyday tasks of life. He is 24 years older than me and looking into his eyes it felt like I was looking into my future. It was unsettling. However, despite it turning out to be a tortuous 6.5 hour journey back home, it was worth the effort and we were very pleased to spend some time with them once more.

There was even a Pyrrhic tale to be told as well. The last time my mother went to her GP (to be vaccinated) the nurse noticed her mobility problems and said she would sort something out to make both her and my Dad’s life easier. After several months’ wait, a vast number of phone calls and emails, a new wheelchair was finally delivered to their house. It is a push along kind, which despite my Dad’s best intentions I think he will struggle with. More importantly it is so heavy, he can’t actually lift into his car boot. So, it sits, unused and cluttering up his hallway. I will try and sort things out on Monday, but I imagine Pyrrhus is probably turning in his grave.

The children and young people of today are all our futures

You know you are getting old when the person sitting in front of you being interviewed looks much too young to have gone through all the training and education required to be a medical consultant. Well at least I did last week. I was privileged to be part of an interview panel aimed at recruiting a new doctor to join our paediatric team. Despite having a brilliant interview, the successful candidate looked much too young to be a consultant. Of course, they weren’t, it was just me feeling my age.

Likewise, last week I also had a chance to meet, eat a meal, and enjoy some great conversations with a group of doctors who were just starting out on their careers. The event was a Junior Doctors Forum. Rather cleverly, the Director of Medical Education had offered a free lunch to all who attended and had invited me as Chair to meet with them and find out what their experience to date had been like for them. Apart from the delightful company this invitation gave rise to, the chickpea curry was simply sublime.

The group were made up of Foundation Year 1 and 2 doctors (FY1, FY2), Junior Clinical Fellows, and Physician Associates. The medical foundation programme is a two year generic programme that forms the bridge between medical school and doctors specialist training. At the FY1 stage, individuals can begin to consolidate the skills learnt whilst undertaking their medical degree. Year two, the FY2 continues this learning whilst at the same time affording more opportunities to take management decisions, strengthening their pathway to becoming independent clinicians. All are appropriately supervised and this was one aspect of their experience that the folk I talked to described as being the most important one for them. I heard tales of the ‘Purple Consultant’ who each day, worked in the Emergency Department and provided on the spot experiential learning for the junior doctors, as well as being there to support them in their diagnosis and treatment decision making. What a great idea!

The group were all incredibly young, enthusiastic, bright, focused, and whilst at times naive, they were all super confident.  The conversations were a real learning opportunity for me. I asked them about their experience of the pandemic. Most said that whilst the pandemic had initially felt like a major hiccup in their journey to become a doctor, they now felt it had actually been a ‘once in a lifetime’ learning opportunity. Most of them had been seconded to work in critical care areas. Initially this had caused much anxiety, but on reflection they felt it was probably the safest place to be, and they reported that none of their colleagues working in ICU actually contracted Covid. They all noted that what had been important in the early months of the pandemic was what they described as ‘fantastic teamwork’.

I thought this was an interesting observation. There was a clear and easy sense of a shared identity amongst the group. It was clear they were all part of a medical family. Yet the conversations were full of examples of how they worked with nurses and other health care professionals, none of which sounded remotely rhetorical or patronising. There was no ‘them and us’, just a straightforward notion of being part of a team. It was a refreshing attitude to witness. However, I was amused by the way in which the group referred to their seniors, it was always with the prefix of Dr. No one called me Professor, despite my title being writ large on my identity badge. I didn’t mind.

As we talked it was hard to find anything they were particularly concerned about. That was the underlying purpose of the lunch time conversations, and I struggled to draw out anything negative. All said they preferred working in what they described as a District General Hospital rather than some of the larger and supposedly more prestigious hospitals in the North West. They felt the learning opportunities were greater with us and there was more opportunity for independent working. The one complaint I did hear mentioned a couple of times was the difficulty in taking time off for annual leave. This was sometimes allocated and felt to be not long enough to really make a difference. I’m on the case. 

Several of the doctors reported that they were going to be doing a FY3 year next year. In effect they were taking a year out of their training to do something different, to recharge the batteries and simply enjoy life again, away from studies and the demands of the junior doctor role. One FY2, a young lady, described her plans to walk the El Camino de Santiago way. 

Now this is something I have always wanted to do, and I have to admit to feeling a little envious of her plans. It’s an almost mythical walk, just about 800km long, starting in France and finishing at the Cathedral in Santiago de Compostela in Spain. Most people doing the entire walk will take some 35 days to do it. It’s a walk that, up until Covid hit the world, attracted some 300,000 thousand people a year. To be fair they wouldn’t all do the entire walk. This year was meant to be a special ‘Holy year’, but like many other things, this has been postponed until next year.

Listening to the young doctor describing the walk to her friends around the table I did wonder if now I would ever do the walk. It’s a young person’s walk for sure. The longest continuous walk I have ever done was the Coast 2 Coast, which is only some 200km long. But I never say never, so who knows? What I do know is that the Birmingham, RAND and Cambridge Evaluation Centre (BRACE) last week published their findings from their early evaluation of the children and young people’s mental health trailblazer programme. You can find out a lot more information about this brilliant programme here. 

Why do I use the word brilliant? Well their interim report showed that the trailblazer approach used in some 1,000 schools across England, with its focus on prevention and early intervention was enthusiastically welcomed and valued. Whilst the new entry to the mental health work force, the education mental health practitioners (EMHPs), was viewed as being valuable, recruitment and retention of these staff was, at times, a challenge. However, the programme is already having a positive impact in safeguarding the mental health of our children and young people. They are our future, and the recent past has clearly had a negative impact on many children’s and young people’s mental health and wellbeing. Whilst it’s unlikely I will be sitting around a table in the future eating chickpea curry and hearing from some of these next generation of potential doctors, I’m confident that with the right support in place for our children and young people, someone like me will be. As I get older and let younger tigers gain a voice, that thought makes me feel good about the future of our health and care system. 

Knowing how to open the Johari Window for a brighter future for the NHS

On Friday I was stuck in a traffic jam on the M6. It’s not unusual, and never more so than on a Friday afternoon. There is nothing you can do other than to sit there, listen to the radio and wait for the traffic to move forward another six feet or so. I was listening to Radio 4’s Last Word, which this week reflected on the life and times of Donald Rumsfeld, who died recently. Donald was certainly a colourful and at times, a controversial person. He served four different US Presidents during his lifetime, the last being George W Bush. It was during this time, as Defence Secretary, that he masterminded the invasion of Iraq following the terrorist attack on the twin towers in New York. It was a war that cost the US over £500 billion and some 4,400 American lives, not to mention the thousands of Iraqi lives lost in the conflict.

He was also a man famous for the way he expressed himself – for example, ‘all generalisations are false, just as this one is’ – but he is probably most famous for his response to whether Iraq actually had weapons of mass destruction (one of the given reasons for invading the country) or not. He said: ‘there are known knowns, these are things we know that we know. There are unknowns, that is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know’. It is a quote that has been used frequently since by many folk charged with strategic planning and management.

Of course, the concept of ‘unknown unknowns’ is not new. Joseph Luft and Harrington Ingham, two American psychologists came up with the notion way back in 1955 (a great year) during their research into group dynamics. Their work led to the development of the Johari Window. It is a model that is used to help individuals better understand their relationship with themselves, as well as with others. I have often used the approach in small group work with students to help them understand the concepts of inter-personal, intra-personal and extra-personal relationships and how people use these in their everyday lives. Indeed, drawing upon psychodynamic and managerialist analytical discourses, a large part of my research and writing has focused on exploring the impact of such relationships on nursing practice, policy, organisation and education. Much of this work being focused on mental health nursing.

I still find it amazing that it was more than 46 years ago since I started my mental health nursing journey. And last week I was taken back to those wonderful days through a visit I made to the mental health unit on our Acute Hospital site. It is an interesting collection of services. There is provision for those experiencing an acute episode of mental ill health; a small forensic ward; and unusually these days, a small service for people with complex needs who are likely to require long term care. It was lovely to be able to walk around the various wards and to have conversations with the staff and patients alike.

Some things had changed, yet at the same time remained the same. When I did my training, we had to wear uniforms, which for men included the ubiquitous white coat. By the time I qualified and got my first Staff Nurse’s job, we were all wearing our own clothes. Last week I was surprised to see the nurses back in uniform once more, albeit their uniforms were modern and stylish. However, they talked about their experiences of working through the early days of the pandemic and the fact they were required to wear full PPE. PPE, and even simple masks were not seen as being helpful in building and maintaining effective therapeutic relationships, the core of mental health nursing. Of course, the nurses all understood why PPE was necessary, but 15 months on, whilst still wearing masks, the other forms of PPE were no longer being used.

The other big issue that remained was the numbers of staff who were having to isolate, because they had been in contact with others who had tested Covid positive. As with other fields of practice, there is an acute shortage of qualified mental health nurses, which the pandemic has brought into clear view. Equally, as in many other areas of health care, the staff were pretty exhausted, although there were lots of smiles to be seen and positive thoughts expressed about the future. I think for me the highlight of the visit was meeting the mental health liaison team. They were the embodiment of the notion that ‘there is no health without mental health’. They worked across the Acute Trust and not just in the Emergency Department. Listening to them talk about their work, it was easy to see that their underlying approach was one of integration and collaboration. 

Whilst they were experts in their field of practice, they worked with other staff in holistically meeting the needs of each individual. It was a far cry from the days of my training where meeting the mental and physical needs was exclusively the domain of either ‘psychiatric’ or ‘general’ nurses. Last week, the way of working I heard described was much more about interdependency which, in an age of collaboration and partnerships, bodes well for the future.

Speaking of collaboration, I was really pleased to see that the Health and Care Bill was introduced to Parliament last week, with the second reading due as early as this Wednesday. It is the start of a process that will see, by next April, the end to the disastrous Lansley reforms of 2012, reforms that have beleaguered the NHS since that time. Whilst there are still a great number of known unknowns arising out of the new legislation, we don’t need to look through the Johari Window to know that there is a much brighter future ahead of us. All we need now is for Sajid Javid to deliver the Prime Minister’s promised oven-ready plan for social care. Something that is now long overdue and cannot come soon enough.  

Eloquent impressions of how to build back fairer in a post-pandemic world

Do you know how the days of our week came to be named? I didn’t until this week. Yesterday I was thinking what a great week last week had been, although, in parts it was very busy. I’m certain my walking miles will be fewer this week than most weeks. For me, Wednesday was the most delightful day of the week, and as I was thinking about this, I suddenly wondered how our days got their names. In the land of Google, it is of course easy to find out the answer.

Apparently, during the fifth and sixth centuries (AD) the Anglo-Saxons brought both their gods and language to the UK. In so doing they gave us Saturday, Sunday and Monday named after Saturn, the Sun and Moon respectively. The following four days are named after gods worshipped by the Anglo-Saxons – Tuesday was Tiw (the god of warfare), Wednesday was Woden (the god of eloquence), Thursday is Thunor’s day (the god of thunder), and Friday, which is the only day named after a female god, Frig (the god of love and sex). So that’s the history lesson over and done with, but before we go, I want to say that last week, Wednesday lived up to its name. I met (well if virtual meetings still count as having met someone), a young lady who spoke with great power and passion in delivering her message very clearly and strongly. I have to say, I was totally impressed. More of which in a moment.

First, did you see the story of Vanessa Reiser last week? What a woman. I simply loved her story, and even more the picture of her taken by George Pejoves. For me it captured her passion, sense of freedom and courage. Vanessa found herself living in an abusive relationship. Her abuser was narcissistic; someone who showered her with affection, only to then destroy her with his abusive behaviour. She was due to marry this man, and had even brought her wedding dress. He, despite asking her to marry him, used the threat of leaving her as his abuse control over her. Her abuse experience was a cycle of idolisation, devaluing and unkindness over and over again.   

Vanessa eventually decided to end the relationship and instead of walking down the aisle, put her wedding dress on and ran some 275 miles across New York to raise money for domestic abuse charities and to raise awareness of abuse. Hotels and restaurants supported her every step of the way. Over two weeks she ran nearly 24 miles a day wearing her wedding dress, raising nearly £8,000 for these charities. I was totally impressed.

But back to last Wednesday and the other young lady who impressed me. It was a heck of a day. My first meeting was an early morning Zoom catch up call. Then it was on to a PhD viva. It is always a privilege to do a PhD examination, and this was no exception. The student’s study looked at patients in mental health secure units in Ghana who had self-harmed. It was both a wonderful conversation and I am sure his research will have a positive impact on individuals here and in Ghana. I was totally impressed.

My next meeting was one facilitated by the folk at NHS Providers. Their analysis of current and emergent health care policy is second to none. Their review was brilliant, provocative and informative. Given the rapid changes that had occurred the previous weekend, coupled with that empty CEO seat waiting to be filled at NHS England, it was a remarkable piece of work. I was totally impressed.  

The penultimate meeting last Wednesday was a celebration of Manchester becoming a Marmot City Region. Sadly because of the prevailing Covid restrictions, it was a virtual meet up. However, it didn’t detract from the enormity of the moment. Michael Marmot himself chaired proceedings with the indefatigable Andy Burnham, Mayor of Manchester, co-presenting. The afternoon saw the publication of research undertaken by the Institute of Health Equity, at the University College London. Mirroring Marmot’s other work, the report (here) focuses on six key themes to build back fairer in a post-pandemic world. These areas will come as no surprise to those folk who know of the deep-seated and lasting problems of poverty and inequalities experienced by so many living in and around Greater Manchester. The six themes are: communities and places, housing, transport and the environment; early years, children and young people; income, poverty and debt; work and unemployment; public health. Whilst the report focused on the Greater Manchester region, there are clear messages to the rest of the UK that far more governmental effort is required to develop (and fund) policies that address those social determinates that can have such a damaging impact on peoples health. Perhaps with a new Secretary of State for Health and Social Care, and a new CEO for the NHS, there is a chance that change might be possible.

What Andy Burnham does so well is to always give a voice to those most impacted by the issues being discussed. At last Wednesday’s event, this belonged to a young lady called Shekinnah Wilberforce. Among the great and the good, she was the absolute star of the afternoon. She spoke of her experience of living through the pandemic. She talked of the anxiety it had brought, the uncertainty she and other young people had felt, and how that had impacted upon their health and wellbeing. It was hard to listen to. However, she also spoke of hope, of positivity, of new opportunities. Someone tried to label this as ‘post-traumatic growth’. I don’t like labels. I think whatever the day of the week, Shekinna would be able to speak with such eloquence and determination about how we all have a part to play in creating a better, fairer world to live in. The young people of today are all our futures, and I was equally totally impressed by this young lady.