Interesting Figures- not just numbers, but people too

Some weeks, if you are fortunate, you might get to meet or hear some really interesting folk. Last week was like that for me. The first person to mention is the fabulous Ruth May, Chief Nurse for NHS England. Last Tuesday, she spoke at the inaugural Pam Hibbs lecture at St Bartholomew’s Hospital, London. It was a great speech, and you can hear it here. She appears, wearing her nurses tartan face covering, at about 7 minutes into the video. Three things stood out for me in her speech. The first was the acknowledgment that to her mind removing the student nurse bursary in England was ‘fundamentally the wrong decision’. I couldn’t agree more. It was a short sighted economically driven decision that we are reaping the consequences of now.

However, the second thing that struck me was despite record numbers applying to study nursing in 2021 last August (possibly the Covid factor), the lowest numbers of new people entering onto the register for many years. Which links to my third reflection, Ruth’s declaration that the target of getting 50,000 new nurses by 2024 was simply not adequate. Again, I can do nothing but admire and agree with her in saying this. Without an appropriately educated and trained workforce, and nurses are by far the largest group in the health care workforce, it will take even longer to deal with both the enormous backlog of care and bring services back into something that resembles pre-pandemic levels*.

I once criticised Ruth in one of my blogs for wearing her nurses uniform on one of those interminable PM Covid TV updates. She sent me a wonderful message explaining the background to that incident and I was glad to eat humble pie in my apology to her. Ruth’s speech last week, was brilliantly timed, wonderfully executed and she said absolutely what needed to be said.

My second person of interest was Sir David Sloman, Chief Operating Officer NHS England. He and a raft of his team appeared to be touring NHS England Regional Office monthly meetings last week. The message he brought to the meeting I was in was one about protecting our ambulance services so they could provide an adequate response to those who most need it in an emergency. To my ears, there were perhaps too many ‘thank you’, to many appeals to use our ‘leadership’ to bring about change, and not enough said about what might be done to resolve the social and domiciliary care services. It felt like Sir David might have read my blog of last week, as what he was saying sounded very much like my thinking set out in that post. I can say it again, patient flow in and out of hospitals is the number one factor which has had the greatest impact on ambulance availability.

Wednesday’s interesting person was completely different.  It was a chap called Grant Harrison. Have you heard of him? I hadn’t, but he has made a huge impact to at least 5 million of us. In 1995, he was responsible for introducing and developing the Tesco Club card. His mission was to get more people to shop more often and spend more money. He achieved this by getting people to do more of what they were already doing. His secret was using data collected each time we shopped at Tesco as way of influencing our behaviour. His story was slightly worrying, but immensely interesting and had parallels for what we might want to be doing in tackling inequalities, improving health and to do that across populations.

Grant was evangelical about how mobile phones might be the key to improving population health. He even went as far to suggest that we might want to think about mobile phones as medical devices (again something I mentioned in a blog in 2021). The success of the Tesco Club Card resulted from giving people something they wanted. Apart from making individuals feel special, and noticed, there were money saving vouchers that reflected what customers had already purchased and other’s that they might want to consider buying. These messages were aimed at families rather than the individual. Just think what we might be able to do if we could use personal data to do something similar with tackling obesity. For example, the average child has no control over what they are given to eat each day. It's parents who have that decision making control. If we could harness social media messaging, in what Grant described as creating the ‘nudge impact’, which to me sounded like little and often, we could bring about change over time in peoples eating habits and desire to engage in physical activity. 

With 64% of the adult population, 14% of children aged 4-5 and 25% of children aged 11-12 being obese, current interventions and messaging are clearly not working. Borrowing from the Tesco Card experience may help us unlock new ways of using data to changing health behaviours. Clearly doing so is not without its problems. Tesco were able to do what they did because they were the sole recipient and holder of personal information gleaned from our shopping habits. We implicitly trusted Tesco’s to safeguard that information, possibly because we benefited. The same is not true in the NHS. However, that shouldn’t stop us from trying.

I have reached the end of my weekly blog word limit and still not mentioned a few other interesting folk I met or heard from last week – so apologies, but please Google them because, like me I think you will find what they have to say very interesting: Gill Galliano; Bevleigh Evans; and Andrew Snowden. And finally, its day 32 of the Russian war in Ukrainian. I continue to keep all those impacted by the war in my thoughts and prayers. On Mothering Sunday, this feels even more important as I think about all those families separated as a consequence of the conflict. Peace not War.

 

*Because it needs to be said, the Covid pandemic has not ended. Community infections continue to rise across all of the UK.  We are now seeing both the BA1 and BA2 Omicron variants at play. If you want to believe the unhelpful messaging about Omicron being a mild form of Covid, look towards Hong Kong, who are now reporting the highest mortality numbers in the whole of the world. Partly, this situation is a consequence of the decision not to vaccinate in age groups in the same way the UK did, and starting with the older and more vulnerable population groups.

Man flu? – actually there are more important things to worry about

I want to start this week’s blog by saying a big THANK YOU to all those lovely folk on social media who have sent me get well wishes over the past few days. You are all very kind, and kindness matters. Always. Last Thursday night I went to bed feeling like I was coming down with a cold – I woke up feeling definitely unwell. Feeling unwell is not a state of being I usually contemplate. I have been relatively healthy most of my life with just the usual colds and coughs, a spell of depression and a couple of surgical interventions. No, I have always considered myself fortunate health wise. 

Over the 2 years or so of the pandemic I have avoided catching the virus, but I was beginning to think my good fortune had run out. By Friday night and not feeling much better I took another lateral flow test thinking I absolutely must have caught Covid as infection rates* are on the rise again. Once again it was negative.

I am a great believer in cognac and paracetamol as ‘catch all’ treatments for colds, flu, coughs and so on and I had self-prescribed both over the last few days. As I write this blog, I am feeling much better, so I guess whatever it was that made feel unwell is passing.

My reaction to feeling unwell and not knowing why, did make me reflect on how we all might have started to change our thinking about our own health, and where we might seek help from when we become ill. It is true to say that primary care services are at full stretch, sometimes making it difficult for folk to gain an appointment, virtual or otherwise. Across England, all emergency and urgent care services have seen a significant, and sustained exponential rise in presentations. In pre-pandemic times, in my own hospital, we would normally expect to see 250-270 people a day. At present we are regularly seeing 370+ patients a day. Worryingly, the numbers continue to grow each week.

Despite my colleagues’ best efforts, a patient’s journey through our hospital, either through being admitted or treated and discharged, can be severely delayed. At times, some individuals may have to wait for many hours to be seen and treated. We are not alone in dealing with these problems. Almost universally, emergency and urgent care services are seeing more individuals who are very sick. There are growing numbers of people presenting with high acuity challenging conditions, where their needs can be complex and unpredictable. All of which can take more time to carefully decide the most effective way of addressing and responding to these needs. Covid precautions add to these challenges. 

The ‘demand’ issue is one side of the coin. The other is making sure we can discharge people out of hospital in a timely way. Like many hospitals, we have significant numbers of patients in beds who are medically fit to be discharged, but have no appropriate place to be discharged to. Some of these folk will need rehabilitation, others, social and/or domiciliary care. All of which can be in short supply. The lack of availability of these services results from many issues. For example, a largely private sector domiciliary provision, many years of punitive reductions in local authority funding, and ever increasing numbers of frail and elderly folk in the population. As I lay in my sick bed, I also reflected on other, perhaps related, factors at play here.

Over the past 20 years or so, families in general have become more geographically dispersed and many communities have become insular and more inward looking. My siblings live all over England, but also in Australia and Bulgaria. Four of my grandchildren live in New Zealand. The concept of a ‘nuclear family’ has in many respects become a transient notion as the reality of ‘extended families’ becomes more common. Some of my grandchildren, for example, have more than two sets of grandparents. I can remember the important role my own grandparents played while I was a child, and they lived just around the corner from our house. My eldest daughter is now over 40 years old, but I can remember when she was born, the whole street we lived on at the time, both celebrated her birth and acted as wise advisors when things didn’t go quite as planned. During sleepless nights, teething, and toddlering, they were always there with some sage wisdom to offer. Of course, some things were based on pure folklore rather than fact. ‘Don’t sit on the hot radiator otherwise you will get piles’ was one I remember – complete bunkum.  

Another thing that is complete bunkum is that we have more extended families today because more people are getting divorced. In fact, the divorce rate in the UK has stayed at an average of 33.3% for the past 50 years. What might be more relevant is the length of time couples have been married before they divorce. Those married for 30 years or more are the group with the highest rate of divorce, with some 47% of couples getting divorced after this time. Which brings with it other problems at a time in life when you could do without them - in particular, isolation and loneliness. The harmful impact of being alone and isolated was something brought into the spotlight during the pandemic. For many reasons, this has become the reality for a much greater number of people than ever before. Research has shown that sudden, disrupted or a gradual lack of social connections can increase the likelihood of an early death by some 26%.  To put that into context, that is a risk comparable with smoking 15 cigarettes a day and is certainly higher than that caused by obesity and physical inactivity.

To put something else into context, that is my feeling unwell for a few days, today is day 25 of the invasion of Ukraine. We were told yesterday that some 6.5 million people are now displaced from their homes and communities within the country with a further 3.3 million refugees having fled to neighbouring countries. However difficult we might feel our own problems might be, let’s keep all those people impacted by this cruel war, and others like it that are still going on around the world, in our thoughts, hearts and prayers.

 

 

*As I write this blog, Covid infection rates are on the increase across the UK. On Friday, the Office for National Statistics reported that one in every 20 people in England were infected, whereas in Scotland the infection rate has hit a record high, with one in 14 people being infected. 

Like all things, this too, shall pass.

Last week turned out to be an interesting week in many ways. On Thursday I was part of a meeting facilitated by NHS Providers. It was a meeting for NHS Chief Executives and Chairs. The first part of the meeting involved addressing some challenging questions around race, and anti-racism. Amanda Pritchard (Chief Executive of NHS England) was part of the panel that explored what these questions might mean for Trust Boards and NHS organisations. She reflected on the NHS England journey in addressing race equality. You can find some of the questions here in the NHS Providers press statement. One take home message for me was the challenge: ‘What we tolerate we permit – what we permit we promote’. It was a thought that resonated with me, not just in the context of moving towards race equality but also in other areas where strong leadership is required and expected.

Over the past two years we have seen many examples of where such leadership has been flawed, not least of all with our political leaders and the so called ‘partygate’. Yes, just like Covid, it’s not gone away. Last Friday marked the second anniversary of the World Health Organisation (WHO) declaring a worldwide pandemic. It’s been a hard two years for many, and sadly for some it still is. While many of us are beginning to look past the pandemic, and to find ways of safely living with Covid, the WHO warns that a new variant has been identified. The Deltacron variant has traits from both the Delta and Omicron variants. It is already starting to rapidly spread across Europe. It is one to keep an eye on but illustrates that Covid hasn’t gone away and we need to remain careful in keeping up the infection control practices we have all become so familiar with during the pandemic.

Another reason for doing just that has to be the steep rise in the number of Clostridioides difficile cases (or C. diff as we refer to it in our quality assurance meetings) since the start of 2022. It is a bacterium that causes an infection of the colon, giving rise to symptoms that can range from diarrhoea to death. In 2020, the last time the rates were published, 107 people in England died from C. diff related illnesses. Across the UK, rates have been falling since 2008. There doesn’t seem to be an agreed reason as to why the cases have started to rise. Possibly the increased antibiotic use during the pandemic might be a contributing factor, or maybe we have started to become less vigilant about keeping up with the covid precautions. Interestingly, the gel we have all been using helped protect us against covid, but it does nothing for preventing the spread of C. diff – but soap and water and regular handwashing does.

Of course, whilst C. diff and Covid are important, today is day 18 of the invasion of Ukraine by Russia. My clogs are still Blue and Yellow as symbol of my support for the Ukrainian people. I keep the Ukrainian people in my thoughts and prayers each day. However, I was interested to read last week about Semyond Bagdasarov, a Russian historian and academic, who incredibly (and courageously) spoke on a prime time state run TV programme, criticising the invasion and war. He was also joined by Karen Shakhnazarov, a film maker who challenged the idea that what Russian troops were doing wasn’t a ‘special military operation’. Both of them now risk going to jail because of their criticism of the Kremlin’s actions. Such criticism contravenes a Russian law passed in the week before last regarding publishing ‘fake news’ about the war. Unlike Trump, the Russian parliament have defined what ‘fake news’ is – essentially any criticism of the war. Actually thinking about it, Trump did something similar – he defined ‘fake news’ as anything that criticised him. If found guilty, Bagdasarov and Shakhnazarov could both spend up to 15 years in a Russian prison. Not a good thought.

Bagdasarov reminded viewers of the disastrous invasion the Soviet Union mounted in Afghanistan in 1979. It was a war of attrition that lasted 10 years. The then leader of the Soviet Union, Mikhail Gorbachev, pulled out after realising there was no ‘victory’ to be had. Interestingly, Gorbachev's family were from Russian and Ukrainian descent. The ending of the Afghanistan war also heralded the end of the Soviet Union, and perhaps more importantly the end of the ‘Cold War’. He was best known for his policy of ‘glasnost’ (meaning openness), which led to much greater freedom of speech and expression. Now 92 years of age, Gorbachev has long been a fierce critic of Putin.

Reflecting on these memories and thoughts a number of things occurred to me. One, all these events have happened in my lifetime. I wondered to myself whether I had really paid any attention to the underlying issues involved. Secondly, the global response to the pandemic, and local responses made to prevent the harm that C. diff can cause, made me very grateful that we have science and good public health practice to help keep us all safe.

The third thought was a rather more reoccurring one: all things will pass. It is a notion that has many claims to its origins, from Jewish and/or Turkish folklore, to references in the Bible. Many famous people (and not so famous I guess) have used the phrase to describe something that will be true in good and bad times, or to note the perpetual oscillation between good and evil, or the bringing down of pride and the promotion of humility. It is a thought that can provide a helpful focus. When things feel hopeless, reminding oneself of the words, can bring hope.

I absolutely can’t imagine what it must be like for all those folk struggling and fighting against the invasion of Ukraine or those who have fled their homes for a now very uncertain future. However, I have to believe that this conflict, like all things, will pass. Across the globe, we must continue to act to stop this despicable attack on a nations freedom and democracy. It is heartening and encouraging to see world Governments of all complexions, major organisations and millions of ordinary folk everywhere, rising up and seriously responding to the challenges represented in that notion of what we tolerate we permit (and what we permit we promote). Peace not War!    

Thimbles, Chip Butties, and Looking after our Children

Sometimes my blog notes, collected over a week, as a kind of ideas stimulator, can be extremely cryptic. So much so that when I come to write my blog, I have little idea what my thinking was at the time. For example, here are some of the notes I wrote down last week: frog in a pan; thimble around her neck; what do we tell the children? and chip butties. Make what you will of any of these.

So maybe, the chip butty is as good a starting place as any. In my mind it is the kind of story that can give good research a bad name. It was a study commissioned by the supermarket chain Iceland and carried out by Nottingham Trent University. Apparently, the perfect chip butty, is made with two slices of medium sliced and buttered white bread, which between them, contain 12 thick cut chips, smeared with tomato ketchup. It’s not a snack I have eaten for many a year, although writing these words now, I could easily eat such a chip butty. However, right now, striving to create the perfect chip butty feels rather like a first world kind of issue, and there are many other more worrying and pressing problems to be concerned about. Not least of which is the continuing conflict in Ukraine.

The pictures and tales of so much destruction, of so many innocent deaths and threats of worse to come have been very distressing. But there have been heart warming stories as well. People from all over continental Europe have self-mobilised to offer aid, food and a place to stay to all those fleeing their homeland. There was the kindness shown to young Russian soldiers captured, and who were bewildered and uncertain as to what they were doing and where they found themselves. I read of several of these young prisoners who only wanted to phone their mothers, to seek comfort in the familiar and I would guess, to seek a restabilising of what they might perceive as their usual normality. War brings about change to all those involved in it, whether folk are directly or indirectly involved.

I think I must have been reflecting on this when the image of a frog in pan came to mind. Among others, it is a story in the book ‘The Age of Unreason’ first published in 1989, and authored by the modern day philosopher and writer on organisational behaviour, Charles Handy. He shared the idea that if you put a frog in a pan of boiling water it will immediately leap out, whereas if you put the frog into a pan of tepid water and gradually heat it, the frog will remain in the water until it boils to death. Probably, this story is an urban myth, and please don’t try the experiment at home. As a metaphor, it works well in perhaps understanding the world’s slow reaction to the threat posed by Putin, a threat that has been around for such a long time. Hopefully the world has now leapt out of the pot and is still able to do something to end the madness that is Ukraine at present.

As a professor in mental health care, I have long disliked the use of the term ‘madness’ to describe anything because of the ill-founded association it has to mental illness. However, the word can more appropriately be used to describe other things. For example, a state of wild or chaotic activity, and harmful activity inflicted upon others. To my mind this begins to describe what is going on in Ukraine right now. If you have the time, perhaps look at this article written by Chris Firth, Professor Emeritus, University College London. At the very least it will perhaps make you stop and think about the connection between what we understand by notions of civilisation and ideas of madness.

On a slightly different tack, one of the things that made me stop and think last week was hearing the account of a father living in a small village in Ukraine. He was talking on BBC Radio 4 about what to tell his children about the war that was moving ever closer to them. At first, he talked to his children of fireworks being let off, of a tractor backfiring, but gradually he found himself forced into having a different conversation with his children. This was a conversation about war, and a war they were involved in. He is not alone. There will be many others facing the same dilemma. I know that some of my children have had similar conversations with my older grandchildren.

Finding the balance between honesty, authenticity and the challenges of possibility and probability is always going to be difficult. Trying to do so with young children becomes even more complex. More often than not, young children have not developed a resilience store that allows them to safely make sense of risk and rationality and certainly don’t have the same moral concepts as adults. What children are very good at doing however, is picking up on the emotions and feelings of the adults around them.

Which is where honesty comes to the fore. Personally, I think it is okay to say that as a parent you are worried about what is going on in Ukraine, that you are concerned for all the families impacted by the war, but you will keep them (your children safe).  Children also often want to do something in response to what they may have heard. I think it can be healthy to find a way to allow them to do just that. It can be a symbolic as painting a blue and yellow arch (like those NHS rainbow arches) to put up in the front room window. It is the little things that often can make the biggest difference.

And a thimble? That is also a little thing, but it was a note to myself that caused me my biggest headache. I could not remember why I had jotted it down. Asking J, who must be the world’s greatest romantic, what it might mean, and she immediately said: ‘The English Patient’. The film is possibly better than the book, but both capture the passion and romance of forbidden love, and intrigue. 

With this clue I was able to go back and have a look again at the story that prompted my note. It was about chickens losing their feathers due to an extraordinarily high wind, something mentioned in the book. Not true of course. The ‘silver thimble’ was due to the fact that I only gift silver jewellery to J. However, like the Chip Butty, in the context of what’s going on in Ukraine, this feels an entirely frivolous thought. Peace not War would be a much better thought to have.