Caring for our wounded healers: no crystal ball needed

It was a funny old week last week, full of ups and downs. Having posted my blog last Sunday focusing on the problems there are in GP land, I began to feel more and more like Nostradamus as the media played catch up with the issues. Nostradamus was a French astrologer, doctor and predicter of future events. His first book was published 400 years before I was born. It is said that he predicted many things, including the Great Fire of London, the rise of Adolf Hitler, both the World Wars, the first moon landing, and even 9/11 and the attacks on the twin towers in New York. He also prophesied the end of the world. As far as I’m aware, this is one prediction that has happened yet.

Mind you last week’s news might make some people feel the end of the world is imminent. Covid19 hasn’t gone away, Brexit is hitting all parts of our lives, including empty shelves in our supermarkets, the cost of keeping ourselves warm going up fourfold, dead pigs stacking up on farms, and fruit rotting in the fields. To crown it all, those folk at the Government Communications Department issued a notice to say there was no need to panic buy petrol, as there was plenty in the refineries, immediately firing the starting gun for people to panic and spend hours queuing to fill up their cars. It was all pretty grim stuff, and I have to admit to resorting to what Frank Lloyd Wright described as ‘chewing gum for the eyes’ – watching TV to tune out the ever depressing zeitgeist.  

Despite the fact we have four televisions in our house, we seldom spend much time during Summer sitting inside watching any of them. I was once an avid watcher of ‘Come dine with me’ and ‘Four in a bed’ and would watch every episode every week – I know, I know, but even these programmes get seldom viewed these days. However, I was home alone last week and in the dark evenings, I played catch up. There wasn’t a great deal that appealed, and flipping through the channels I came across one of those ambulance programmes, which follow ambulance crews over a 24 hour period. The programme was part-way through as I settled down to watch the stories being told.

Underlying each of the stories were often high expressed emotions of fear, anxiety, despair, loss, coupled with pain and discomfort, which folk couldn’t deal with themselves. The paramedics featured were professional, compassionate, kind and very human. Whilst I got a sense of the emotions the ambulance call handlers were going through; it was hard to discern what each of the paramedics might be experiencing as they dealt with the different calls. If I’m honest, I was caught up with what I observed was the way they interacted with each of their patients, and didn’t think how facing so much trauma day after day might be impacting upon their mental health and wellbeing.   

That changed for me last week following my participation in a Wellbeing workshop for Chairs, Chief Executives, Wellbeing Guardians and Staff-side Chairs. It was facilitated by my colleague AlisonBalson, who is Director of Workforce at my old Trust, Wrightington, Wigan and Leigh Teaching Hospital. Just an aside, the term ‘workforce’ really grates, as does the term ‘staff’ when referring to our colleagues. I’m on a crusade to change the language and narrative around the folk we stand beside in delivering our health care services. But I digress.

The workshop started with three powerful stories, told by the individuals themselves. The first was by a former paramedic who took us through her slow descent into depression and suicidality. I’m not sure how she got through the telling of her story. I and, I suspect, many others, were choked up as we listened to her tale. She had risen through the ranks, and was both a highly skilled advanced paramedic as well as holding a managerial role. Her mental health problems stemmed from an incident she was part of, that occurred in the very early hours of the morning, involving a serious road traffic accident in which five young people were seriously injured.

She told us what it felt like to manage the situation, having to wait over an hour to get the support she needed in terms of other ambulance crews and rescue services. All the young people involved in the accident eventually lost their lives. She went to all their funerals. Over the following six months she couldn’t get the trauma of what she had been involved in out of her mind. Her performance as a paramedic suffered, her family relationships disintegrated, and she experienced clinical depression to the extent of contemplating taking her life. It was a powerful story of vulnerability.

It was also a story of the need for us all of to recognise when something is not right with our colleagues, and the need for organisations to find way to ensure the mental health and wellbeing of individuals is a paramount and continuous concern. The workshop took us beyond the impressive array of wellbeing interventions and support that’s been developed during the pandemic. Good as these are, a more fundamental approach is required that ensures we don’t put colleagues in situations where their mental health might be impacted without there being a compassionate and caring response proactively available. I’m signed up to this and will work with colleagues to make sure it happens.

It was a week of ups and downs, and I do want to mention two folk who were definitely responsible for some great ‘ups’ last week: Emma Rogers and Mamoona Hood – two Matrons at Stockport Foundation Trust, who last week led on our #FallsAwarenessWeek – they were successful in engaging with folk across the entire Trust, and there was much shared learning, fun, patient, colleague and volunteers’ involvement and of course, cake. They even got me to wear a bright orange t-shirt! – now that takes some doing.

Finally, my up and down week is so, in part, due to remembering one of my younger brothers, Christopher, who died this past week, 14 years ago. He was a rascal, he was indomitable, a loving father and a generous brother. His premature passing seems so unfair and I miss him very much.

 

Ps Ambulance Series 8, starts this Thursday, 21.00 on BBC, and features the North West Ambulance Service – just saying.

Dr Do Little – an urban myth!

The last time I went to see my GP was November 2020. The practice had contacted me to get a flu jab. It was a brilliant experience. I had been asked to arrive no more than 5 minutes before my specified time, and had to be masked and social distance. I have to admit that I was sceptical about having a precise appointment slot, but when my time arrived, I got my flu jab bang on time. Due to my age, I was also given a mini health MOT. My medication was reviewed and there was a chance to talk for a few minutes with two earnest medical students. Fortunately, I have not had to go back since that time.

My Covid19 vaccinations were done at a hospital vaccination hub, and my repeat prescriptions have been switched to a 22 week rolling prescription, which I get filled at my local chemist when the tablets run out. I can get help online, and I can use our urgent care centre if ever there was a need to. Fingers crossed I won’t need their help. I’m content, but clearly others aren’t.

It would be impossible to have missed the stories of anger and abuse many GPs have been subjected to in the last few months. It’s been said such behaviour is the result of patient frustration at not being able to get an appointment or to see their GP in person. Last week there were media reports of some GP practices receiving bomb threats, having their premises covered with offensive graffiti and many practices seeing a rise in threatening behaviour and violence towards staff, both in person and through social media. Such threats have resulted in many staff going on sick leave, and for others, leaving their jobs. It’s not a good place for many GPs and others working in primary and community care right now.

The public frustration appears to be fuelled in part by the perception that GPs are no longer offering face-to-face appointments, and where they do, getting an appointment is almost impossible. The situation appears to be a legacy from the early days of the pandemic when many practices were shut to the public and consultations went mainly online or over the phone, and an unprecedented, and what has been an exponential rise, in demand for health care. It’s an urban myth that GPs have ever stopped seeing patients in person. All the way through the pandemic, if someone needed to be seen, they were. GPs and their primary care colleagues have continued to work throughout, and indeed, they have played a major part in ensuring the UK vaccination programme was so successful.  

For some folk being able to access a GP virtually has been a real bonus. My parents, both now elderly, live on their own in Cardiff (a round trip of some 470 miles for me). Recently I have been trying to sort out some health and mobility issues on behalf of my mother. Trying to resolve these problems would have been nearly impossible without being able to communicate online. Actually, it was an advanced nurse practitioner that proved to be the ‘gatekeeper’ able to open the door to getting my mother the help she needs – a thought I will come back to in a moment.  

Now regular readers of this blog will know I try and steer clear of politics, but I could not write a blog about what is going on in GP land without saying something about our current health secretary, Sajid Javid. Last week he was urging GPs to see their patients face-to-face. The thinking being such an approach would increase their effectiveness as ‘gatekeepers’ to diagnostic services and specialist services, and so reduce the waiting lists. On Tuesday he told his fellow MPs that the Government ‘intends to do a lot more’ to ensure in-person consultations go ahead. He didn’t actually say what this doing a lot more might actually entail. Now I quite like Sajid Javid. Despite being a solid Thatcherite, he is a man of integrity, a pragmatist and has a well-defined moral compass – think back to his resignation as Chancellor of the Exchequer when DC ordered that all his Treasury aides be sacked. He is also a very astute and intelligent man and supported J during her election campaign. He has held all the major Secretary of State roles during his time as a MP. 

Having said all that, I think he has got it wrong this time in his thinking about GPs. Increasing the number of face-to-face consultations won’t increase their ability to act as ‘gatekeepers’ to specialist services; in the main they can do most consultations virtually, and have done so successfully for the last 18 months, but that rather misses the point. If we keep seeing them as the ‘gatekeepers’ we will never achieve the transformation necessary to seize the opportunities presented by place-based health care. Today, the single ‘gatekeeper’ notion is an almost Kafkaesque concept (‘Before the Law’), and no longer helpful. It creates an image of the ‘real’ health service being somewhere else, perhaps in one of the PMs 40 shiny new hospitals? The reality is that much of the ‘real’ health care should and could be done in primary and community care services. The reasons we currently have such a high waiting list problem is complex, but it’s not a consequence of GPs doing little during the pandemic.

Alongside thinking differently about population health, I think we need to re-think who is involved and/or takes responsibility for signposting patients to specialist services. As well as expert clinicians and practitioners, we need GPs and other health care professionals to become leaders, navigators, and interpreters of patient need. Only then will the opportunities of place-based approaches to population health be realised in reducing the ever increasing demand upon acute services. In an age of advanced practitioners, rapid uptake of digital health technologies, and algorithm driven decision making processes, there are many alternatives to the notion of the GP as being the only ‘gatekeeper’ in town. We might have to think differently about how we pay people, how and where they work and so on, but that is part of that transformational thinking that needs to happen. Change in primary care is possible, it’s exciting and, in many places, that transformational thinking is already bringing about better ways of enhancing the health and wellbeing of folk.

Ps – nearly all the patients we have in our ICU are people who have chosen to not take up the offer of a Covid vaccination. A poignant example of how our thinking on population health needs developing.

Remembering the music that makes memories

In the weekend where we remember the 20th anniversary of the tragic events of 9/11, I want to introduce you to the Nigerian word for remembrance ‘ncheta’ (pronounced ‘cheta’). Why, you might be asking yourself? Well hopefully all will become clear shortly, but first a short story about ‘sod’s law’. There is an old (1871) Lancashire proverb that says, ‘the bread never falls but on its buttered side’. It’s a well-known example of ‘sod’s law’. Richard Bronson, an American professor emeritus of mathematics, is a leading expert on ‘sod’s law’. He tells a lovely story about a man who once dropped his bread and it landed buttered side up, thus defying the universal law noted above. Apparently, the man was so astounded he rushed to his rabbi to ask for an explanation. At first the rabbi didn’t believe him, but was eventually convinced that it must have happened. However, he didn’t feel qualified to answer, so he passed the question on to one of the world’s greatest Talmudic scholars. After months of waiting for an answer, the scholar finally replied: ‘the bread must have been buttered on the wrong side’.  

Bronson also offers a slightly different interpretation of ‘sod’s law’ – ‘the degree of failure is in direct proportion to the effort expended and to the need for success’. It’s something J and I came face-to-face with last weekend. We had spent many months carefully crafting two playlists for our #Wedstock21 wedding celebrations. One was to be played as we ate our meal, the other to be played as we danced. It was a labour of love. We were so proud of our choices, and had even woven into the dance playlist, requests from our guests. As so often happens, pride comes before a fall.

The large room was beautifully laid out and decorated, the sun shone, and our guests were mellow from drinking lots of bubbles. We sat down to our meal, and pressed play to start the music. The conversation from our 75 guests drowned out the music. We turned the music up, but then it was too loud for conversation. It was turned down again, and we spent the following three hours just occasionally hearing a snippet of the music being played. It was ‘sod’s law’. There wasn’t anything we could do about it. We hoped for better things with the dance music, and indeed a few guests did dance. The music was great but many were content to tap their feet or watch the younger guests do the dancing.  Again ‘sod’s law’ prevailed. All those months of carefully selecting, reviewing, changing arguing over what stays in or taken out was in vain, although we do have two great playlists for driving too now. Whilst the music was important to us, it clearly wasn’t to the same extent for others.

As I was thinking about the importance of people attach to music (or not), I recalled a piece I had read recently about the use of music therapy in Nigeria. I have only been to Nigeria once. I found it to be a very frightening place. I was there as a guest of the University of Lagos’ West African Student Nurse Association, and to present a paper on Nurse Leadership. I was made to feel very welcome by the students, almost overwhelmingly so, and likewise my academic colleagues also extended a very warm welcome too. On the tour of the School of Nursing I noticed that the library had very few books. For many months afterwards I shipped boxes of textbooks donated by my university colleagues back in England, and only stopped when the shipping costs became prohibitive. I have never been back, but do keep in touch with some of the students I met on the trip. One even completed his PhD.

But I digress. I think it was memories of my visit to Nigeria that made the article about the use of music in mental health care stand out. I have been to several countries in Africa, and mental health care is often very basic compared to the familiar models of mental health services in the UK. It is particularly the case in sub-Saharan Africa. That’s a sobering thought when, often in different parts of the UK, mental health care is still very much a ‘Cinderella’ service, under resourced and understaffed. So, it was great to read a positive story about one mental health service in Nigeria that was using music as a way to engage therapeutically with patients.  

In a city called Ibadan, about 130 kms north from Lagos, staff at the psychiatric unit of The University College Hospital have started to use music as part of their therapeutic approaches. The project is led by a lady called Bola Otegbayo who has degrees in both physics and music. She uses music in group sessions as well as with individual patients. What resonated with me was her acknowledgment of the need to ensure the right piece of music is used when choosing to use recorded music in the sessions. There is much research to show that music can be stimulative or restorative, but in some situations, music can also be the source of despair. 

However, central to her work is the opportunity to establish and develop a therapeutic relationship through the co-production of live music. Such an approach has been shown to be helpful to folk whose lives have been impacted by injury, illness or disability, particularly those who might also have communication difficulties. Music has also been found to be helpful in people living with dementia. It can often trigger an act of remembrance, catching a glimpse of a life that was perhaps experienced differently.

Yesterday I saw a Twitter posting of how music was being used in a setting closer to home. It showed the work of Iris, a therapist who works in the Manchester critical care service. One of her patients called John had been on the unit for 100 days and Iris had developed a therapy plan for the week which included live music, which she played herself. He found the music beautiful and relaxing. You can hear the music for yourself here – but if the link doesn’t work for you, I think it will be another case of ‘sod’s law’. I wish John all the very best and hope his recovery continues well. I don’t Iris, but I think after all the NHS has been through over the last two years, she epitomises the best of the best.

 

Ps – when I looked up the distance between Ibadan and Lagos, my computer defaulted to showing the distance between Ibadan and Blackpool where I live. Its 4494 miles and would take me 97 hours via the Trans-Saharan Highway. But ‘sod’s law’ being what it is, I would probably get a puncture before I got onto the M6!

All you need is love (and a good cheese and onion pie)

I have been writing and posting this blog at 05.00 every Sunday morning since 2009. In all that time I have never missed a Sunday. Every Sunday, without fail. I have only once pre-scheduled a tweet posting. However, this blog posting is the second time of doing just that. The first time was almost a year ago when it was the day after I got married to J. While she is very tolerant of my early morning postings, clearly it was a non-starter on that occasion.

Why the second time? You will have to wait to find out. First I want to talk about Nigel. It’s not his real name. I don’t know him, and only met him the other day while I was out having a pub lunch. He came in with two women, one of whom was helping him as he appeared very unsteady on his feet. He was an elderly gentleman. It became very clear that somewhere along the line Nigel had suffered either some kind of head trauma or illness that had left him with a large degree of neurological impairment. He struggled with his speech (aphasia), had very poor control of his movements, looked gaunt, had no teeth and at times, looked completely disorientated.

The two women on the other hand, were smartly dressed, and looked fit and healthy. I had ordered my meal, cheese and onion pie (the house speciality), fresh garden peas and baby new potatoes in a rosemary dressing. While I waited a sipped a rather good Malbec and half listened to what the trio were talking about. Half listened is a funny term, but for me, as an avid people watcher, it allowed me to gain a glimpse of the trio’s situation.

They sometimes talked about Nigel as if he wasn’t there, and he didn’t participate in the conversation other than to occasionally utter something that was often too difficult to understand.  One of the women was clearly Nigel’s wife, and when she helped Nigel choose his meal, it was with a firmness that didn’t seem to brook any argument. S/he ordered the same meal as me and when it came, his wife cut up the food into small pieces. Nigel appeared to enjoy his cheese pie as much as I did, but his eating was fast and furious. His wife leaned across the table and spoke to him in such a calm and loving way, saying ‘we don’t eat like that, do we Nigel?’. He slowed down and finished his meal quietly.  

The trio left before me, and I doubt I will come across them again. I tell you this story as seeing them brought to mind so many memories. I worked for a few years as a Charge Nurse in a learning disability service in Wales. It was a time that many of the hospitals were resettling their residents into much small community settings. Part of the resettlement programme was to re-introduce individuals into the everyday activities that many of us take for granted, shopping, eating out, gardening and so on. I spent many a lunchtime having a pub meal or walking around our local supermarket with our residents. Almost all of these folk had been in hospital for many years and often appeared bewildered by what they were now experiencing. It was a slow, but rewarding process.  

I like to think that we undertook this programme and took part in the resettlement activities with care and love in our hearts. It might have been a different kind of love to that demonstrated by Nigel’s wife, but I think it was something more than just doing our professional best. These were therapeutic encounters where the emotional ‘being’ of nursing trumped the ‘doing’ of nursing tasks. Love in a personal relationship is fine; thinking about love in a professional relationship is much trickier. One of my favourite authors and psychotherapist, Irvin Yalom, touches upon this subject in his book, Love’s Executioner: ‘Perhaps it is because love and psychotherapy are fundamentally incompatible. The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection. I hate to be love’s executioner.’  He is describing a therapeutic encounter with an elderly patient called Thelma who is possessed by a long past love affair that limits her ability to live her present life fully. His book is worth reading for those interested in understanding more about their self and their self in relation to others.

Likewise, way back in 2020, Theodore Stickley and Dawn Freshwater published a thought-provoking paper that explored ‘The art of loving and the therapeutic relationship’. The paper challenged how in the pursuit of evidence-based practice the centrality of the caring relationship can sometimes be lost. It explores the concept of clinical caritas, and why individuals might choose to enter the nursing profession. The paper develops a framework where the art of loving within nursing care is presented. This outlines the balance between concentration, discipline, patience, concern and activity. Collectively these elements provide the boundaries where love may be expressed within the scope of professional practice. In health and care practice we care for others. Such caring is about people and how we relate to them. Our specialist knowledge and knowing are important parts of building and nurturing these relationships, but just like Nigel’s wife, they should be brought to bear with love and care.

That second pre-scheduling. Well just under a year ago, like yesterday, I put on a black suit, purple clogs, and silver bangles. There was a special reason then and it was nothing whatsoever to do with health and social care. Like then, the reason I’m not writing and posting this blog at 5am today for real is that I’m curled up in bed with my beautiful wife J, after celebrating our marriage with friends and family yesterday at our very own wedding festival. It was a special day where our love was shared and which went a long way to make up for our Covid restricted wedding celebrations last year. I will be back next Sunday, alive and kicking, until then, stay safe everyone.