Who pays the Health Care Piper?

Last week I found myself standing in line at our local pharmacy waiting to pick up my prescription. Whenever I do this, the Rolling Stones’ song ‘You can’t always get what you want’ comes to mind. However, my pharmacy is not a Chelsea Drug Store, it’s just a normal Cohens store (there are other chemists available). As I was standing there with the Rolling Stones song playing in my mind, I became aware of the man in front of me discussing with the store assistant the cost of getting his prescription filled (I don’t know if he was Mr Jimmy or not). In the UK each item costs £9.35, and he had 3 items, but didn’t have that much money.

In the end, he only took 2 of the items prescribed. I know there are plenty of provisions for people on certain benefits, or who have certain health conditions which exempt them from paying for their prescriptions. But there will be others, perhaps like this man, who for whatever reason simply haven’t got enough money. I wondered how many times this dilemma gets played out every day. Such situations provide us with a glimpse of the real costs of health care. However, depending on what the prescription was for, the real cost of Mr Jimmy’s health care may well have been heavily subsided.

Our little dog Dylan recently became seriously ill with a liver infection. He required emergency veterinary care and then ongoing in-patient care for four days last week. Not a single decision, test, or treatment was undertaken until we had given our consent and signed to say we would pay the costs. Those costs mounted up at an alarming rate over the four days, and ended up north of £4000. Thankfully we have pet health insurance, but even this has its limits. Sadly, he is still unwell, but he is getting better each day. The experience has been salutary in reminding us of how fortunate we are in the UK to have a National Health Service that is almost completely free at the point of service.

It is not the same for many other countries; notably in the US, where health care is largely private health insurance based, or for those who qualify, Medicaid is available. Since the pandemic started nearly 77 million people now receive Medicaid, an increase of some 10%. Each one of these additional Medicaid enrolments represents an individual and/or family whose income has fallen low enough for them to qualify. This doesn’t reflect well for the world’s largest economy. The US also spends more on health care than any other country. Currently this stands at £8,136 per person each year. This compares with £3,371 per person in the UK, the world’s fifth largest economy.

What I also find interesting is that in many States in the US, people on Medicaid will be charged for pitching up at A&E for something that is not an actual emergency. This is a cost the individual has to bear themselves and is not covered by Medicaid. I wonder what would happen to the current extraordinary demand being experienced by emergency and urgent care services in the UK, if such a charge was levied. I would expect overnight attendances would fall by at least a third.

However, such a scenario is unlikely to ever happen in the UK. Likewise, we are unlikely to consider the suggestion made last week by Martin Hirsch, the Head of Hospitals in Paris, who raised the question of whether individuals who had refused the Covid-19 vaccination ought to be charged for emergency and critical care should they become seriously ill with the virus. His suggestion is fuelled by the frustration caused by difficulties facing the French health care system similar to those here in the UK. Just as here in the UK, many French hospital beds are filled with Covid-19 patients, 80% of whom are unvaccinated. These beds cannot be used to reduce the waiting lists of folk who may be facing life-limiting conditions. Hirsch says this is unfair.

One day in critical care costs the French taxpayer £3,850. The cost of the vaccination is £16.60 per dose. There is a ‘pay for your health care and get reimbursed’ approach to health care provision in France. People have to pay up front for most health care and are then reimbursed by the State, although it is not a 100% full reimbursement. Even so, I don’t think Hirsch’s suggestion will gain much traction. Like health care services everywhere, nobody wants to get into the situation of patient selection – do we make smokers pay for lung cancer treatment or charge those who are morbidly obese because they eat too much? I don’t think so.

The NHS, like many other international health care systems, has always provided comprehensive and unconditional health care to everyone who needs it. It’s a service provided by professionals who are non-judgemental in the way they use their skills, knowledge and experience to help others at a time where the individual cannot help themselves. The provision of care and treatment should be and is often free from any economic, social, cultural or political constraints. In the UK, health care is also largely free at the point of accessing it. 

However, not every cost can be measured in monetary terms. The last two years have shown what a huge emotional and physical price has been paid by those working in health and social care services across the UK. There can be no denying the huge cost in terms of mental health and wellbeing there has been for many providing care during the pandemic. Sadly, we are not done yet. Let’s remember to be there for each other. Likewise, let’s remember these challenges will pass. 

Snow in the Sahara and other Tales of the Unexpected

I read, with dismay, the announcement last week that BT intended raising the cost of its broadband and phone services by 9.3% in March this year. It will be an additional financial burden for many households to bear, alongside the higher costs of fuel, food, and energy bills. April brings the new National Insurance increase and rises to our Council Tax bills. Why are the charges for broadband and phone usage going up? Well, it is said that there has been a 90% increase in broadband use since 2018 and a 79% increase in mobile phone usage since 2019. There are 80.97 million mobile subscriptions in the UK. The UK population stands at just over 67 million people.

People in the UK spend an average of 3 hours and 23 minutes on the phone each day. Over 65 million people use their phones for internet use, whereas only 48% of us actually use our phones to make a voice call each day. BT note that the pandemic and working from home and the popularity of streaming films and games has led to increased use of their data networks – hence the planned price rise.

The pandemic brought about many changes to our lives, not least of which has been how we work. Despite what some folk may think (PMs and the like), hybrid working is here to stay. Many people have been able to enjoy a better work/life balance as a result of adopting an agile approach in where and when they work. Health and social care have also seen innovation brought about by new technology. We now have virtual wards, telephone consultations, and virtual outpatient clinics. More of which later.

Although these days I’m largely retired, I’m privileged to work as a Chair for a large acute hospital. Although I could easily work from home in undertaking this role, I choose to travel in and have a physical presence on site each Monday and Thursday. I enjoy working and being with people and going in twice a week means I get to spend my time doing just that. It’s a bit of a commute; 70 miles there, and then 70 miles back, but I don’t mind. It provides me with time to think and to listen to music or the radio. I like Radio 4 best. Last week, as I was travelling home, I tuned into ‘Think with Pinker’. If you haven’t caught this programme yet, have a listen here. Each programme provides a fascinating exploration of how our minds work, and how this impacts upon our behaviour and decision making.

The programme I listened to explored false memories, and how these might result in wrongful convictions in some court cases. False memories are not deliberate and can happen as a consequence of many things.  Someone who holds a false memory will often maintain some certitude in the veracity of that memory. A false memory can involve remembering something that occurred, but in a way that is very different from what actually happened. More commonly, a false memory deals not with forgetting something that actually happened, but remembering something that has never taken place.

False memories can be ‘created’. Research undertaken by one of the programme’s presenters, Elizabeth Loftus, Professor at the University of California (and one of the most influential psychologists of the 20^th century) showed how easy it was to do this. She described an experiment which involved showing the participants advertisements featuring images of Bugs Bunny. Subsequently, the researchers found many people believed they had seen, touched, or spoken with Bugs Bunny on a trip to Disneyland. This was unlikely to be the case as Bugs Bunny is a Warner Brothers’ creation and would have no place at Disney. It is perhaps easy to see the difficulties judges and juries might have in sifting through evidence that might be made up of false memories! Knowing what to believe might be more than just a challenge. For example, how many readers of this blog knew that it had snowed in the Sahara Desert last week? It did! And this was the fourth time it had done so in the last 42 years. If someone had told me that, I’m not sure I would have believed it.

What we believe to be true can have all kinds of consequences for us, as was shown in the outcomes of a Harvard clinical trial, published last week. This showed that 75% of side effects caused by the Covid vaccination were likely to be more psychological rather than a direct consequence of the jab. It is a phenomenon known as the ‘Nocebo effect’ – people experience a reaction because they are expecting one. The most often reported side effects were headaches and fatigue. Most side effects and, in particular, serious side effects are extremely rare. It is, however, true that in some cases, the second jab might give rise to some minor side effects as the body reacts to vaccine.  

Knowing what is a genuine physical reaction caused by the vaccine rather than that caused psychologically can require skilled, knowledgeable and experienced individuals making an assessment. I met one such person last week on my visit to Mastercall Health Care, one of our partner organisations providing out of hours and out of hospital care. In addition to providing face to face care, they use a great deal of technology to keep people safe and cared for.

The person I met was Jacqui Doherty, Advanced Clinical Practitioner, and Lead for Technology Enhanced Living. She showed me some new digital monitoring equipment they were just trialling. It was impressive. Using an internet-supported system, Jacqui could remotely monitor patients’ health and wellbeing, interact with them by phone or video link and give advice about changes in an individual’s symptoms. It was a system that also gradually educated folk with long-term conditions to more effectively look after themselves.

It was a glimpse of the future, yet it was here right now. Given the imminent BT price rise*, perhaps doctors and other community staff will soon be able to prescribe data plans for high end health care data usage. It has to be cheaper than keeping someone in a hospital bed!    

 

* I know from personal experience that BT have a great track record of protecting and supporting vulnerable individuals and families. Well done to them. I’m just not sure why when I turned 66, I became a vulnerable person. 

Scaffolding, but not as we know it Jim.

It is funny how something small can trigger a train of thought. I read an article last week that reported on the acute shortage we have of scaffolders in the UK. Given that we seem to have constant waves of shortages of everything from lorry drivers, toilet rolls, fresh fruit and vegetables and, it seems, honest politicians, perhaps I shouldn’t have been surprised.  The story did, nevertheless, stir my little grey cells. Until the middle of last week, we have lived with a dirty sponge poking out of the end of a scaffolding pole, which was located directly in front of our front door. It was not our sponge, nor even our scaffolding pole. It was, however, our front door, which is actually located on the side of our house.

In early 2020 our next door neighbours decided to sell their house. They had lived in it for some 34 years and, to be fair, they hadn’t done much in the past 20 years in terms of modernisation, painting and decorating and so on. Despite being in their seventies, they started to prepare their house for sale with great gusto. Which, at first, was wonderful to witness. It was the time of the early lockdowns. We didn’t do ‘working afternoons with wine’ in our garden; there was, after all only J and me in the house/extended office environment. We did however like to sit outside in the sunshine, but often had to give up as the sawing, grinding, cursing and hammering from next door made it impossible to sit outside for too long. Like our Prime Minister, we could usually endure it for 25 minutes or so, before retiring inside away from the noise of people working. The building work went on for much of 2020. Fast forward to February 2021 and the house is sold, and the new owner, immediately starts work on stripping out the whole house right back to the bare brick work.  

Long story short it’s been a challenge. We kept expecting to see Kevin McCloud turn up with film crew in tow. Thankfully he didn’t. Our new neighbours ‘Grand Design’ includes re-rendering the outside of the house. After a near fatal accident where one of the workmen fell off a ladder while starting on this work, the whole house has been wrapped in scaffolding for the last five months. It hasn’t just been Covid-19 that made 2021 a difficult year for us. Living next to a construction site has been a nightmare.

But actually, none of the above is what I wanted to write about – the original story sparked a train of thought about a different kind of scaffolding. Students of psychology and/or education will know of the concept. It is most often associated with the Russian psychologist Lev Vygotsky, although he never actually used the term in his writing. Scaffolding as a concept can be traced back further to the likes of Foucault, Derrida, Geertz and White; that latter possibly the most well-known for his work on how scaffolding can be used in therapy and learning environments. An important element of this scaffolding is what has been described as the ‘zone of proximal development’. This zone bridges the gap between what is known and what is possible to know. It is within this gap that learning occurs.

In my work with my long time collaborator and writer, Professor Sue McAndrew, we developed this notion further to suggest that learning and understanding best occurs at the gap between knowledge, and knowing, that is ‘not knowing’. Scaffolding can be useful in helping others move from being dependent on others for understanding and explanation to independence in thought, understanding and action. Whether it is in the therapeutic or educational encounter, scaffolding requires the presence of someone with knowledge and skills beyond that of the patient or learner (the knowledgeable other). It is the therapist or teacher that guides the patient or learner on a journey of personal discovery. This journey helps with the acquisition of the skills and learning required to resolve mental health challenges and/or problems that might inhibit normal growth and development.  

Thinking about all of this did make me wonder whether scaffolding might also be a useful way of conceptualising the Health and Care Bill, currently making its way through the House of Lords. Last week I was fortunate to be part of a conversation with Baroness Glenys Thornton. She is a formidable woman, who has been a long time campaigner against inequalities of all kinds. She has, since the age of 16, being a member of the Co-operative Party. She was also a former Labour Minister for Health and is currently shadow spokesperson for health. Our conversation started with a discussion on the process of the Bill’s passage through The Lords, and then what some of the issues were that had been raised by some 302 amendments submitted since the Bill was in the House of Commons. It was an insightful discussion.

My take home message was that the Bill is reminiscent of my neighbour’s scaffolding. In itself, it isn’t a home or even a house. The scaffolding is there to enable a transformation to occur. Once that transformation has happened, the scaffolding should be removed. Those amendments mean that we haven’t got the scaffolding in the right place just yet. There are too many dirty sponges to be seen. We should not end up with an Act of Parliament that constrains ambition, or transformation. The Act should be there to facilitate the achievement of its ambitions. Top of which are to more effectively deal with health inequalities, deliver place-based services, make best use of new technologies and reduce the need for acute hospital services. 

Sadly, social care reform doesn’t feature much at all in the Bill, but that is something for another blog. However, talking with Glenys last week, I came away with a much greater sense of confidence that these issues were at the forefront of people’s minds, across all sides of the House of Lords. I hope in the fullness of time The Lords will be able to provide the Government with a well-thought through and evidence-based second opinion.    

The art of mental health care

One of the things I have been most grateful for during my academic career was the opportunity to travel the world. I’ve been able to visit places I might have only ever dreamt of seeing short of winning the lottery. Teaching, research and publications were (and still are) the currency that gave academics a voice. You really needed to be good across each of these aspects to ensure your voice was heard by as many folk as possible. One great opportunity to use your voice is at conferences. Prior to the pandemic, conferences were lively gatherings where people could meet, present their research and thinking and, of course, network. Many folk, like me, also enjoyed the opportunity to visit foreign lands.

Often the conferences I spoke at were those that focused upon mental health, mental illness and wellbeing. It’s true to say that over the years I would meet some familiar faces at these conferences, and strong, lasting friendships grew out of these regular ‘meet ups’. One of these relationships was with a legend in mental health care – Phil Barker. He was 20 years in front of me as an academic, and was a prolific author and researcher. He was also a highly regarded psychotherapist and nurse. In 1987, he became the first Professor of psychiatric nursing in the UK. I became Professor of mental health care in 2006. This was an interesting year for lots of reasons; more later.

Phil and I also shared other similarities. Both of us only wore black. We both loved silver jewellery. Whereas I let my hair grow long, he kept his short. but had the most amazing ZZ Top beard. We both enjoyed philosophy and the use of words to explore ideas. He always wore red clogs, whereas my clog collection is a lot more colourful. He is a lifelong runner, and runs every day. I’m a walker, and I walk every day. Now you may be asking what has any of this to do with the price of eggs? It’s a question my mother would often pose.

Well in 2006, while staying at Trinity College, Dublin, Phil had an epiphany. He realised that most of the people he encountered in his work as a psychotherapist were shadowed by ‘the ineffable’: that is a kind of intuitive understanding of what it was that troubled them, but an inability to put it into words. The following day he resigned his Professorship at Newcastle University. He returned to his native Scotland and using art, began to explore the ‘ineffable’ that shadowed his own life. Retiring from academia, Phil left behind a legacy that continues to influence contemporary mental health care. In 2004 Phil and Poppy Buchan-Barker (Phil’s wife) published what has become a seminal piece of work, ‘The Tidal Model: A Guide for Mental Health Professionals’. It was a book on mental health recovery. The book drew upon almost five years of research with his colleague Dr Chris Stevenson. At the time, it was a significant alternative model to the prevailing psychiatric theories of care. It emphasised how individuals living with a mental illness could benefit from taking a more active role in their treatment and care.

There isn’t room in this blog to explore every aspect of the Tidal Model; you can listen to a brief explanation by Phil here, or a slightly longer version here (look out for the red clogs). Phil defines the Tidal Model as ‘a philosophical approach to the discovery of mental health. It emphasises helping people reclaim their personal story of mental distress, by recovering their voice. By using their own language, metaphors, and personal stories, people begin to express something of the meaning of their lives. This is the first step towards helping recover control over their lives’. Phil describes a number of key philosophical assumptions that underpin the Tidal Model.

These are: a belief in the virtue of curiosity; recognising the power of resourcefulness, instead of focusing on problems, deficits, or weaknesses; respecting the patient’s wishes instead of being paternalistic; accepting the paradox of a crisis as an opportunity; acknowledging that all goals must belong to the individual patient; and recognising the virtue of pursuing elegance, the simplest possible means should be sought. Fundamentally, the mental health professional should believe that recovery is possible. Perhaps this sounds rather obvious, but sadly it’s not always the case.

Now you might still be wondering, interesting as all this is, what does it have to do with the price of eggs. Well last week I self indulgently poured myself a hot Vimto and enjoyed one of the Guardian newspapers ‘long reads’. If you have time for a cuppa, you can also read it here. It is a beautiful and eloquent piece written by Gavin Francis. In nearly 20 years as a GP, he has, as a result of the pandemic, become more aware of the concept of recovery and the individual experience of illness and expectations of wellness. His many years of medical training took for granted the western bio-medical approach to the body. What Gavin, like Phil, has come to realise is that illness is not simply a matter of biology or pathology, but also one of belief, culture, sociology and psychology. For me there are a couple of sentences in his piece that capture the notion of recovery so well. In Gavin’s own words: ‘All worthwhile acts of recovery have to work in concert with natural processes, not against them… …a doctor who sets out to ‘heal’ is in truth more like a gardener who sets out to ‘grow’ – actually nature does almost all the work’. It seems to me, as health care professionals, we should try and keep this in mind, as we work with our patients and their loved ones.  

And 2006. Almost the last time I saw Phil was in 2006 in Alice Springs, Australia. It was a great conference in lots of ways. He was a judge of the conference papers and awarded first prize to the one that my long time writing partner, Prof Sue McAndrew and I had presented. The story doesn’t end there. The following year, I was in Finland, attending the public defence of one of  my Finnish colleagues as part of his PhD studies. Phil, was one of the external examiners. We raised a glass or two. These days, under the new name of Phil McLoughlin (in honour of his grandfather), Phil has now returned to his artistic roots and has taken up painting full time. In his own way I’m sure he is on his own path to recovery. I believe all health care is an art. For me, the art is when to use the science and when to let it lie.      

Walking into the New Year

Well, 2022 is with us and this is my first blog of the new year. I’m starting this blog by offering my congratulations to all the health and care staff who were part of this year’s New Year Honours. You have all made a significant contribution to lives of others, and for that I want to say a big THANK YOU. Particular congratulations go to Kenny Gibson, a nurse extraordinaire, an early risers club champion and long-time supporter of this blog. His MBE is richly deserved!

It’s a strange time of year. Last Thursday was my eldest daughter’s birthday. She is 21 again. I love her to bits and I’m so proud that she also works in health care, and so equally makes a difference to others each and every day. Her birth was a great and joyous occasion. I actually missed her being born, as I had run out of cigarettes and left the maternity unit at Swansea Hospital to buy some more. When I got back, there she was. I really couldn’t believe it. A perfect child. I long ago stopped smoking.

Her birth was made even more important as just a year before, my wife had endured a late miscarriage. It was an experience we both found almost unbelievably difficult. I was woken up by my wife who, in extreme pain, was in the middle of miscarrying. There was blood everywhere. It was a bewildering time. An ambulance was called, and back then, one came within minutes. I didn’t know what to do. I rang some friends and told them what had happened, and for some reason lost in the passage of time, we all headed off to Alexander Place, and sitting outside, watching the lights of London, drank whisky until the early hours of the morning. It was a surreal time. My wife recovered, and just over a year later we had moved to Wales, I started my nursing career and my eldest daughter was born. She has three children of her own now, and they are three of my eleven grandchildren.

Unusually its seems, they all know how to do the washing up after each meal. I say unusually, as it appears many young people today have lost the ‘skill’ of washing up. Dishwashers and fast food are allegedly to blame. The Office for National Statistics notes that 50% of households in the UK now have a dishwasher. We joined this number last year, but I refuse to use it. I prefer to do the washing up the old fashioned way. I also don’t eat takeaway pizza out of the box, but decant it onto a warm plate. They are also active children and grandchildren who like being outside ‘doing things’.

There is lots of evidence (see here) that physically active children are able to concentrate better, and have a great sense of wellbeing than those who choose not to exercise. The Daily Mile in schools is so successful because of these evidence-based benefits. Growing a love of the great outdoors, and doing something active when you are younger will also clearly benefit you in later life. I have, for the last few years, been a proud supporter/contributor to the #NHS1000miles initiative. You can read all about it in Kath Evans’ blog. She is an ultra-runner, and her running achievements are simply outstanding. However, you don’t need to be an ultra-runner to take part in the #NHS1000miles initiative. In fact, you don’t even have to be a runner. You can notch up those miles riding a bike or swimming for example. My wife J, does horse riding, which gives her extra miles. She tells me it is actually considerably harder and more strenuous than it looks.  I’m a walker. Last year I walked 2,446 miles.

I’m also fortunate to live by the sea and have hills and mountains close by. Getting out on those hills or walking on the beach is one of my greatest pleasures. Hopefully it is also helping to keep me fit, healthy and improving my wellbeing too. Walking also gives me time to think, to problem solve and to plan. A walk on the beach can clear my head and certainly elevate my mood. Others have noticed this too, and I don’t mean my good mood.

During the last two years, against the backdrop of the pandemic, research undertaken by Sport England noted that 24.7 million people said they had taken up walking as a leisure activity. Likewise, in September 2021, the Department for Transport published research that showed people in England walked an average of 220 miles a year – the highest number of miles since records began 20 years ago. The shift seems to have occurred during those dark days of national lockdowns, when there was only the possibility of taking one form of exercise a day. You could do this alone or with other members of your household. I find it fascinating that, when other forms of leisure activities are unavailable, such as during the lockdowns, so many people took to something as simple as walking to gain their pleasure.  

As the year was coming to an end, J and I took a walk up a very popular local fell called Nicky Nook. It is situated on the very edge of the Forest of Bowland by the village of Scorton. To get to the top of Nicky Nook, there is a climb of nearly 200 metres, the first part of which is very steep. It was wonderful to see so many others on the same walk. Families, large and small, older folk and even a couple of younger fell runners were all out for a New Year’s Eve afternoon in the sunshine and fresh air. There was a great sense of a shared community. And maybe that is it. Walking, and it doesn’t have to be in the countryside, connects you more deeply with the world around you in a way that modern day life often doesn’t allow. In an ever more challenging world, such connections seem to me to be especially important for our health and wellbeing. If you are not already a member of the #NHS1000miles club, give it a try and I think you will find there are even more connections to be made.