The Devil is always in the detail

One of the stories I read last week was of Kevin Spacey being accused of sexually assaulting 3 men. The alleged offences occurred whilst he was artistic director at the Old Vic theatre in London in the early 2000s. The truth will come out in time, I’m sure. The story caught my attention. Whilst I enjoyed many of the films he has starred in, I have never given a thought to whom Kevin Spacey might be in real life. I have only ever thought about him as the particular character he portrayed in his many films. Two of his films stick in my memory. The first was American Beauty, a disturbing psychological and satirical look at small town American communities, beautifully captured by Sam Mendes. The other film is an earlier one, The Usual Suspects. The film has a superb twist at the end and the famous line ’the greatest trick the devil ever pulled was convincing the world he didn’t exist’ – you need to have seen the film to understand the context. The meaning behind this idea is something for another time.  

In any event, Spacey has but a walk-on part in this blog. He is a means to an end. It was whilst reading about his troubles that my mind turned to the line about the devil from the film, which in turn, and perhaps strangely, resulted in me saying out aloud, the devil is always in the detail. Now as J and many of my colleagues will attest, I’m not a details kind of person. I like the challenge of big ideas, of creativity and innovation, of moving forward at pace. My approach to the world has sometimes seen me come unstuck, usually because of an unintended consequence hidden in the detail of my decision-making or actions. However, whilst I might suffer the consequence of not paying attention to the detail, there are others who will expressly do anything to avoid any of us looking at the devil in the detail.

Think about the great ‘cost of living giveaway’ announced by Rishi Sunak last week. The newspaper headlines looked great. How many of you, like me, just for a moment thought you would be actually receiving a cheque for £400 in the post? 

The devil really was in the detail - none of us will actually get the £400 in cash, it will be paid in monthly instalments as a reduction of our monthly energy bills. Of course, for those struggling with the ever increasing cost of living, all of this package will help. However, personally, I think this is a bit of ‘sticking plaster’ and won’t do much to fundamentally alter the vulnerable position many people are in.

The cynic in me fleetingly wondered if the timing of the ‘great giveaway’ announcement was to distract us from the ‘lawbreaking by lawmakers’ news last week. Sue Grey’s long-awaited report was published last Wednesday. It may have contained a little too much detail for some people. For many others this detail will have reinforced the sense of outrage they have at what was going on at the heart of government while so many others were obeying the rules. 

And don’t get me started about the Prime Minister’s rewriting of the ministerial code last week! Removing the phrase exhorting ministers ‘to uphold the very highest standards of propriety’ and the seven Nolan principles of public life: integrity, objectivity, accountability, transparency, honesty and leadership in the public interest from the Code’s foreword probably tells you all you need to know about the importance of reading what is or what is not contained in the detail of such codes; and what it might mean for the way the current governmental leadership will behave and make decisions. I don’t think it bodes well for anyone.

Now if you are thinking this week’s blog is a bit of a polemic, you would be right. The political outcomes of last week have left me feeling very angry. It is not just because of the direction I fear some of these machinations are taking us in. What continues to be important, of course, is to maintain a careful Foucauldian eye on the creeping intervention of the State into our everyday lives, the erosion of our freedoms and the right to determine our own destiny. I’m not particularly politically active, but I’m sure like many others, I will continue to share my views and feelings on what I think is an ever precarious place for the UK to find itself in.  

My anger is also a consequence of the apparent disregard shown in some of the past weeks’ revelations to the work many of my colleagues have been doing for the past 27 months during the Covid-19 pandemic. It was such a difficult time to be a health care practitioner. My colleagues continue to work hard at providing high quality, safe services. These are colleagues where being aware of, and acting on the detail, can often mean the difference between a good life or a good death, and the difference of minimising the harm from trauma, disease or health inequalities.

Last week, in my Trust, I heard of the detailed approaches and actions being taken to eradicate falls in hospital, and ways to reduce the number of folk acquiring pressure ulcers. And across the North West region, I head of the work being done to move people living with a learning disability or autism out of hospital, and back into a community setting. All of these different initiatives were being carried out by knowledgeable, skilled and experienced colleagues. They understand both the strategic direction and also the importance of recognising that when translated into practice, it will be the attention to detail at an individual level that will really make a difference.  

My colleagues and many others across England, are beginning to bring to fruition the personalised care ambitions set out in the NHS Long Term Plan. For these colleagues, the ‘devil in the detail’ means finding out ‘what matters’ to every individual they encounter in their practice, and then wrapping an approach to care around them that best meets these needs.  

Ok, my anger has dissipated; writing helps me with this. Normal service will be resumed next week.

A Tale of Two Women, Pizza and Possibilities

There was much to choose from in my reading last week. One of the articles I read really struck a chord and caused some discussion in our household. It was an article written by Jo Barker-Marsh. Jo is an unpaid full-time carer for her son. He lives with significant sensory processing issues. Jo is currently claiming universal credit. You may have also seen the article, but if not, you can read it here.

Jo describes an incident where she didn’t feel able to cook a pizza for her son. Having bought one small value pizza, she subsequently didn’t think she could justify the cost of turning the oven to cook it. Her son was distraught and very upset by her decision. Jo uses the pizza incident as an illustration of what it is like to live in poverty at a time of spiralling everyday living costs. Their story really made me stop and think about what that must be like for so many people.

I have never really been in that position. I come from a large family (I had 6 brothers and sisters) and we were never rich, but neither were we poor. I cannot remember being without anything. I was fortunate to be the eldest child so escaped the spectre of having to wear hand me downs. However, as the eldest child, my parents honed their parenting skills on me by trying out their approaches to the everyday challenges of growing up. I think I was possibly a challenging youngster too.

As I grew up and started my own family, I worked as a nurse, and way back then, the salary was just as poor as it is in comparison with today’s salary rates. So it’s true, money was often tight. I was prepared to do anything to earn extra cash. At the time I lived in rural Wales and if you weren’t fussy there were opportunities to earn extra money. I have chopped down Christmas trees, painted houses, put up fences, even driven tractors at haymaking time. Every extra penny helped and over time, I was gradually able to put my life on a more financially secure footing.

I think the despair evident in Jo Barker-Marsh’s story probably comes from not seeing a way out of her current situation, > Indeed there was a sense that things were only going to get worse for her and her son. Sadly, and unlike the rather fatuous Safeguarding Minister, Rachel Maclean, I don’t think there are any easy answers. Getting a better paid job or working extra hours is not an option for many people. I know I was fortunate back in the late 70s to be able to find additional work, but in today’s world, where for many folk a zero hours contract is the norm, there are simply not the same opportunities.

I do like what some supermarkets are doing to help. Recently in both Tesco’s and Morrisons I was offered the chance to purchase a bagged up food bank contribution alongside my own shopping, something I was very happy to do. Asda have re-introduced their 10% discount for key workers including those working in the NHS, in social care and the armed forces. Iceland is offering a 10% discount to folk over the age of 60. It is not a great deal, but like in my early days, every penny saved, can help.

Clearly, international issues continue to impact on the rising cost of living. It is day 88 of the war in Ukraine. This tragic conflict continues to not only be devasting for the Ukrainian people, but is contributing to world food supply chain shortages. The impact of adverse climate change adds to these problems in other parts of the world. Likewise, adverse climate changes are said to be responsible for the continuing high cost of household electricity and gas. A cold winter in Europe last year resulted in stored gas levels being much lower than normal, and hot weather in Asia resulted in more gas being used for air-conditioning – likewise, geopolitical issues have meant that the international demand for gas and oil continue to outstrip supply capacity, with a consequential rise in prices.

Now as regular readers of this blog know, I try and steer clear of making political points. As such, I offer no comment on whether the UK government should introduce a ‘windfall tax’ for the big energy suppliers who have benefited from these abnormally high energy prices. I’m not sure, other than saying every penny saved helps, what such a tax might do for Jo Barker-Marsh and the many other people in her situation. Something has to give, and my view is that our political representatives need to show a little more leadership and application in trying to reduce the impact of the cost of living crisis, particularly on those families who are already vulnerable.

Against this backcloth, I was pleased to read a different story about another formidable woman last week. The story struck me as being both ironic and important as we wait for the outcomes of the Messenger review into the leadership of health and social care services. This was the story of Samantha Jones. If you haven’t heard of her before now, I can tell you she is someone who you soon hear a great deal about. Samantha is a former nurse, who worked her way up in the NHS to become the Chief Executive of two very successful NHS Foundation Trusts. She was recruited into the Prime Minister’s team last February, as part of the ‘partygate’ reorganisation of Downing Street. However, it was only last week that the extent of her role and span of control was revealed. She has become the first Chief Operating Officer for the Downing Street operation – a formidable challenge. If anyone can bring some much needed change and order to what appears to be a shambolic and out of control culture, at the very heart of our government, she can!

I no longer practise as a nurse, but in my mind, I remain and always will be a nurse. Every day nurses make a difference to so many people and do so in so many ways. I’m sure Samantha will be the same, and perhaps, in so doing, begin to find ways in which we can all help folk like Jo Barker-Marsh to no longer worry every day about whether she can cook a pizza for her son or not. We can all strive a for a fairer world. 

A May 2022 Happiness Blog

Well folks, I find that today is my birthday! I don’t know where the past year has gone. At one time, during my hedonistic period, I didn’t really think about time being a finite thing. It didn't seem to matter that once a day had gone you couldn’t get that time back. Now in a much calmer period on my life journey, I’m absolutely aware of each day that passes. My lovely wife, J, sometimes complains that I don’t stop and simply do nothing. Of course, I do. However, there is also so much I still want to do and fit into each passing day. For example, in the spirit of #OneLifeLiveIt I spent time yesterday with my eldest daughter and youngest son and five of my grandchildren both celebrating, sharing stories, playing games, and of course eating plenty of cake. In the evening we had neighbours around for a retro style dinner party.

Today I will be celebrating my birthday with J. Later this morning we will be walking to an open air music concert at our award-winning Stanley Park. It will be only the second bandstand concert since the pandemic started. We have both missed these Sunday afternoon concerts, sitting outside with a picnic, a glass of wine and more often than not, wall-to-wall sunshine. Later on, there will a special meal and I’m sure despite tomorrow being a school day, a glass or two of bubbles. Of themselves these are little things. Together they make a much bigger thing – that is a feeling of happiness. I’m not one for science fiction, but it was the famous sci-fi author Kurt Vonnegut who reminded us to ‘enjoy the little things in life, because one day you’ll look back and realise they were the big things’. It’s the little things that can often bring us the magic of happiness; something I will return to shortly.

But first, wasn’t last week simply full on?! There were many things to reflect upon. The war in Ukraine still hasn’t ended, and daily we hear stories of abuse and cruelty that almost seem to be straight out of a ghastly Netflix film. It is day 81 of the war and there seems no end in sight. Winning the Eurovision competition seems scant compensation for all that has been lost (and well done Sam Ryder). It was also mental health awareness week, with a focus on loneliness. It’s a subject close to my heart*.

Thursday was International Nurses Day 2022. I’m sure, like our hospital and my friends in the virtual community, much was done to celebrate the role of the nurse, and nursing’s contribution to health and care of individuals and the communities from which folk come. 

I fell into nursing as a career. I always wanted to be an artist, but couldn’t do that, so I fancied becoming a lumberjack. After many false starts (I was a Sainsbury’s management trainee, a window dresser, a blacksmith’s assistant), I became, what were called way back then, a nursing assistant. I loved the job. I worked in a mental health hospital and it felt like I had a natural affinity for this area of health care.

I was persuaded to do my nurse training, and the rest is history. I loved being a mental health nurse and the things I learnt way back then have stood me in great stead ever since. My biggest joy (it’s my birthday so I can be a little self-indulgent) was becoming the Dean of what was then the largest School of Nursing in England. Oh, what a privilege. Despite all the usual irritations of working in a large, heavily regulated organisation, the opportunities to allow so many people to find their pathway into nursing was what got me up each morning and ready to face whatever challenges came our way. I never took that responsibility lightly. These students were going to be part of my future, as they graduated and forged their own careers. Indeed, I think hardly a week goes by without me having to answer that question of ‘you don’t remember me, but…’ from someone who studied in our School at the University.

Now in retirement (well almost), I have so many fond memories of those times, and all the opportunities that I had. I was able to travel the world, write and be published, do research, influence policy, meet so many interesting people, and all the time learn so many new things. In lots of ways, those 10 years were a very happy period in my life. Other things make me happy these days. In no particular order I would note: walking on our beach; our garden; my wonderful wife, our children and grandchildren; Dylan the dog, our several cats, chickens and goats (well maybe not the goats), Billy the parrot; fine red wine; my role as Chair at Stockport NHS Foundation Trust and all the wonderfully folk I work with there. And finally, I guess the approach to life that is represented in having two incubators, each containing 6 eggs, sitting on top of our kitchen work tops bringing Indian runner ducks into the world. Do we need any more animals in our lives, obviously we do! 

As I thought this might be a pretty idiosyncratic collection of what might make me (or anyone else happy), I checked with the longest running study on happiness. It is the Harvard’s 84 year old Study of Adult Development. You can find it here. According to the study there are many factors that can lead to a happy life. A happy childhood helps, as does being focused on nurturing the next generation, and you don’t need to have your own children to do this. Being altruistic, helping others less fortunate than yourself are important ways of nurturing others. Spending time with loved ones is important. Forget that hedonistic lifestyle, drink less, be more active, and stop smoking. It’s also important to be able to let go. Don’t have regrets. Worry less about failures and mistakes and focus more on all those little things that bring you happiness. Look forward, seize the day, and if you can share each day with others that you care for, then so much the better.

 

* The happiness study’s Director, Robert Waldinger noted that close relationships are the strongest predictor of happiness, more so than money, fame, or anything else – on the other hand, loneliness kills – it’s a powerful a killer as smoking or alcoholism in terms of shortening people’s lives.

Kindness always matters, no ifs or buts, always.

I’m so glad to have enjoyed a few days of heavy rain. Everything in the garden has perked up, and the rain hasn’t deterred me from getting outside and getting on with life. As well as our garden, the rain was also good for my little ‘guerrilla garden’ which sits in the grass verge that lines our street. It is wonderful to live on a road that boasts grass verges, albeit they are not very wide. Despite it being a somewhat hostile environment due to the road being a busy one, if left unattended, the grass grows tall, we get daisies, buttercups and other wildflowers. Sadly, they are seldom allowed to grow too tall. Along come the council parks department on their sit-on mowers and literally shave the grass as close to the ground as they can get.

One of the first things I did when I moved here was to plant a cherry tree in the middle of our verge. I also planted daffodils, snowdrops and crocuses. The tree has survived somehow and after the first year when the council mower cut all the plants down, I’m left alone now to tend my verge. Our little patch has been added to with plants from our garden. This year I planted some lupins as an experiment to see if they could survive the dry and windy conditions. It may only be a very small patch of colour, but it attracts a lot of attention. Other folk living on the road have started to plant daffodils, and mow their own verges. It gives me a sense of community. I belong here and I feel part of something bigger.

I have been doing ‘guerrilla gardening’ for many years now. For a few pounds it’s possible to plant bulbs, sow seeds and create stunning flashes of colour on those all too often neglected pieces of land. I’m not alone in doing this of course. Those fabulous folk at Incredible Edible have been successfully growing fruit trees, herbs and vegetables on spare bits of land in and around their local communities for years. From a small start in Todmorden, the idea has spread around the world. I hope the idea will continue to grow (sorry). With the cost of living rising each day, growing your own food either by yourself or with others has to be very attractive.

Eating something you have grown is also satisfying in so many ways. These days we grow our own tomatoes and globe artichokes. Given the spiralling food costs, we might have to rethink our garden, however. I found it interesting that during the first pandemic lockdown, many people started to grow their own food. One of our neighbours could not grow and sell his tomatoes, cucumber and pepper plants fast enough to meet the demand.

There is a great deal of research that strongly suggests growing thing, gardening and being out in green spaces is good for our mental health and wellbeing (see here). It’s more than the physical exercise (which will release endorphins). Growing something is a form of caring. It can give us a sense of purpose, give rise to a feeling of achievement, and for some, it can become a creative opportunity to express who you are. I think like walking, gym membership and so on, prescribing a packet of seeds should be in the social prescribing formulary.

We are fortunate to have a garden, but there are many folk who don’t. Finding somewhere to grow even a small amount of food in such situations can be a challenge, but not an insurmountable one. Offering to help a neighbour who for various reasons might not be able to manage their gardens is one idea. There are many other benefits to doing something like this. We saw during the pandemic how loneliness took its toll on so many people. Regularly working in someone else’s garden can help overcome this, as well as providing food to share. It can be a win/win situation.

Loneliness, and its impact on our mental health and wellbeing is the focus for this year’s Mental Health Awareness week, which starts tomorrow. See here for detail of how you might get involved. There are plenty of ways for us all to do something toward helping others. We saw during the pandemic; it’s what communities can do so well. This was a theme of a webinar I was part of last week. Hosted by The Good Governance Institute it featured the totally charismatic Paul Gilluley. Paul is a forensic psychiatrist, which I know from personal experience, can be a very difficult end of mental health care to be in, but he is also Medical Director of East London NHS Foundation Trust, and Medical Director Designate for the North East London Integrated Care Board. 

From the off, Paul acknowledged and recognised the importance of the experience, knowledge and community connectedness many third sector and voluntary groups can make to really making a difference to the health and wellbeing of others. He was passionate about how we might harness this and we spent an engaging and fast-paced hour looking at how engagement with communities might happen – and what the possible outcomes might be.

He drew on his experience of leading the vaccination roll out and the importance of understanding what was important to diverse communities in making this happen. He talked about the importance of language in attempting to engage with others. Very much like I have said to many thousands of my students - learn to listen, take time to listen and if you are to ask questions, start with asking people what matters to them. He understood that the folk who live somewhere or have a distinct culture know what it’s like to be part of that community and what it might take to make for a better life.

Paul was truly inspirational, and he renewed my determination that we really can make integrated and care a reality at a place-based level, in localities, and in our communities. I leave you with a quote that he left us with. It’s from the famous author Henry James. There are three things that are very important in life. The first is to be kind. The second is to be kind. And the third is to be kind. I would add, kindness matters, always.

The NHS is a People Organisation

Goodness me it’s the 1^st of May already. One year ago, I started as Chair of Stockport NHS Foundation Trust (SFT). I have enjoyed every moment of the past year and look forward to many more. It’s my blog, so I want to use it to say a big THANK YOU to all my SFT colleagues who have worked, (and continue to work) so hard to make a difference every day to so many people. You are truly wonderful.

Sadly, there are others who are not remotely wonderful. It is day 67 of the war in Ukraine. The stories of cruelty, despair, death and destruction continue to fill our media. The pain and torment etched onto the faces of so many folk caught up in the war is almost unbearable to see. Closer to home, Partygate rumbles on, and we have yet another MP caught up in a sleaze row. I’m certain that many people will find it hard to accept that Neil Harris opened the porn website by accident. Particularly as he apparently managed to do so on two separate occasions. However, it certainly wasn’t by accident that Boris Becker has ended up in prison. He was found guilty of hiding huge sums of money whilst declaring himself bankrupt. Again, this is not the action of a honourable and trustworthy person. And I’m not sure how one loses a £38 million pound fortune.

Mind you I have never had anything like that sort of money. Sadly, I didn’t win the Euro lottery on Friday, although I did spend some time thinking about how I might have spent the £133 million jackpot if I had won it. After giving some to my family and perhaps buying some land and a new house, I quickly ran out of ideas as to how to spend the money. 

Such a situation would never occur if you happened to be funding the NHS. In fact, the £133 million would only keep the NHS going for 8 hours. That is right, 8 hours. The NHS costs nearly £373 million each day to run. That is a staggering £136 billion each year. The true cost when you include public health (including grants to local authorities), the training and education of NHS staff regulating the quality of care and the cost of dealing with the Covid-19 pandemic is actually just over £190 billion a year. Now that is a lot of money.

It also represents an awful lot of activity. Those great folk over in the Kings fund have a fascinating website that breaks down the cost of different aspect of health care – have a look here. For example, the cost of someone visiting their local A&E department varies between £77 - £359 depending on the A&E department and the emergency care provided. If you are taken to A&E by ambulance, it will cost the NHS £292 to get you there. Whereas a 9 minute consultation with your GP costs a bargain £39. Just under 50% of NHS funding goes to pay the costs of most people working in the NHS. It’s a people rich organisation, more of which later.

One of the final new Acts of Parliament squeezed through last week was the Health and Care Bill. On Thursday the Bill received Royal Assent, becoming the Health and Care Act 2022. The Bill has been hotly debated since it was first published last July. Rightly so in my opinion, as this is the biggest change to the underpinning legislation for the NHS in over a decade. The Act removes all of the legal impediments that have prevented the much needed development of a more integrated approach to the provision of health and care. The ambition to foster more partnership working, collective decision-making and greater collaboration is to be realised through the creation of Integrated Care Systems, managed by Integrated Care Boards (ICB).

Each ICB is charged with working towards better health for all, and when they need it, better care for all. There is an explicit requirement to ensure the efficient and effective use of all NHS resources (an evidence-based approach). Lastly to ensure that everything that gets done works towards reducing health inequalities. It’s a tough ask, but long overdue. We have to stop or at the very least, reduce the impact of the social determinants that have a negative impact on people’s health and wellbeing.

Thankfully the proposed additional powers sought for the Secretary of State for Health and Social Care to ‘interfere’ in the workings of local Foundation Trusts was defeated. This is an important outcome in terms of preserving the right of Foundation Trusts to be accountable to their local Council of Governors (elected representatives of the communities the Trust serves) for the quality and safety of the services provided. This accountability, however, will need further exploration in the context of Integrated Care Systems, and the move towards greater system decision-making.

As regular readers of this blog will know, I do try and stay clear of politics. However, there is one aspect of the new act that I am very disappointed in. It was the amendment to the Bill that would require the Secretary of State for Health and Social Care to report every two years (to Parliament) on how the government was planning to ensure we had an effective workforce in health and social care. Despite being fiercely defended as a positive requirement by members of the House of Lords, the amendment was defeated. We currently have some 110,000 vacancies across the NHS, and the Act does nothing to ensure a long term workforce plan is in place. Given that the NHS is one of the world’s largest employers, with some 1.2 million folk working in it, this just seems totally unacceptable and wrong.

The NHS is a people organisation. The incredible people working in it look after others at times when, for whatever reason, they can’t look after themselves. The NHS is made up of our people and we owe it to them to look after them now and in the future.