Tony’s ABC of great healthcare: Agency, Being, (with others, and being a nurse) and Compassion

A lot of things happened or didn’t last week. Northern Rail left me stranded at Manchester Piccadilly Station last Sunday evening. No buses home. A wet and windy night. A distraught J coming to pick me up, a 3 hour round trip. But they are giving me £11.00 compensation. Whoopie!  

Then there was our laser-focused, grammatically fixated (cares more about commas than comas) new Secretary of State for Health and Social Care and her back of a cigar packet plan for saving the NHS. As a plan, ‘Our Plan for Patients’, doesn’t actually tell us anything new, and is unlikely to fix anything in the here and now, and feels pretty pointless. I feel very frustrated that once again the suggestion is that the very people who were there for the rest of us during the last 3 challenging years are being blamed for the difficulties facing the NHS today. She is the 5th Secretary of State for Health and Social Care during the last 12 years of the Conservative government, and I can’t help but wonder if the finger of blame should be pointed elsewhere and not at patients or health care professionals.  

And although I try and steer clear of politics in this blog, here is a word of warning to the wary. Therese has her new ABCD team at the Department. It includes Neil O’Brien, who earlier this year declared that the 6,000 new GPs promised by his government would not materialise by the 2024 deadline. As an alternative, he thought we should lure retired GPs off the golf course by paying them lots of money. Shades of Aneurin Bevan perhaps. Robert Jenrick joins this dream team. He, at least, has some previous health and social care experience. But just how have we reached a position where appointing the ‘twice lock-down restrictions-breaking’ disgraced former Housing Minister, is seen as a good thing.

For different reasons, I also decided perhaps one can have too much of a good thing. Last week I read one of those fascinating BBC long reads on the subject of supermarkets (now I bet you weren’t expecting that). Did you know that on average we make 221 trips to the supermarket each year? I didn’t. Too much of a good thing? How many of us have just popped into the supermarket for a pint of milk and come out with a carrier bag full of stuff. I have. So, I have changed my habits. I walk to the local supermarket, with just 1 bag. I only buy what I can carry back in that bag. It makes for some interesting choices. Do I buy 1 or 2 bottles of wine and forgo something else because of the weight? It also means I’m more careful with what I buy, so I waste much less. There is a health benefit too, as I now need to walk there more than once a week, so I accrue even more steps towards my #NHS1000miles target.

Somehow this approach feels less frenetic and more slowed down. It was something I enjoyed on my recent trip to Portugal. Way up in the mountains, the nearest shops were to be found in a delightful village called Coja. Whilst there is no Tesco, Sainsbury or even an Aldi, they did have a little supermarket that reminded me of my youth and the early supermarkets we had on the high street. I even found a bottle of wine that was just right for writing blog notes. It was a village where people paused at the Boutique da Tuxa, a bijou pavement café, to take a coffee, eat a simple cheese roll, relax with good conversation and just watch the world go slowly by. Of course, we don’t all live in a mountain village, but we can all pause and take 10 minutes to just sit and practise some mindfulness.

There were goats there too. After chickens they are one of my favourite animals. I have kept many over the years, and even today we have 2 pygmy goats in our ever-expanding menagerie. They are both girls, and although they are called Hansel and Gretel, luckily, they’re not into pronouns. Where I stayed in the mountains, one morning, I was woken up by the sound of goat bells tinkling outside. Getting up I was amazed to see a lady leading a few goats up the street and on to the terraced pastures. We exchanged smiles and I like to think we shared that moment of tranquillity together.

So, I was delighted last week to read of a positive health story that involved goats. Well strictly speaking goats and people. It was the story of Streetgoat. They are a group of folk living in and around Bristol who, across 4 sites around the city, keep goats for milk and meat. They have been doing so for over 7 years. It’s a membership organisation made up of 30 households. Each household pays an annual fee of £70, and everyone has to promise to milk the goats once a week.

The activities of the Streetgoat group addresses many of the important determinants that impact on an individual’s health and wellbeing. They don’t have to rely on supermarkets for milk and meat, and even taking the £70 into consideration, it will be cheaper than having to do that too. Given that the amount of milk each goat gives varies at different times of the year, some of the milk can get turned into fresh soft goat’s cheese, and fresh goat’s cheese is absolutely delicious. Goat-keeping gives folk a purpose, provides company and connection with others. There is always something new to learn, appreciate and gain a sense of achievement. Some of the time, taking the goats to feed, you will be outside, interacting with nature.

Goats are gentle, sensitive creatures and all have a distinct personality. Being around them and caring for them is also great for one’s mental health and wellbeing. Best of all, there is nothing like getting down to milking on a cold morning, and snuggling into the side of goat, feeling its warmth and contentment and enjoying the rhythm of milking. It’s magical. Of course, just like Therese’s plan, keeping goats for therapeutic reasons won’t solve all the challenges and problems facing the NHS, but the story reminded me there is so much more we can do to prevent folk from becoming ill in the first place.       

Time out to simply sit and watch the world go by

This week’s blog comes from a small village in the mountains of Portugal. It’s a beautiful place called  Monte Frio. I’m here as a guest of my childhood friend Keith and his lovely wife Ana. Like me, Keith is retired. He has the best of both worlds, an apartment in Matosinhos, Porto, near the sea and a house up here in the mountains. We both love music, and we both have large collections of musical instruments – Keith’s collection is more eclectic than mine. Mine is mainly dominated by famous name guitars (Fender, Martin, Gibson and so on). J doesn’t share my passion for collecting musical instruments (how many guitars does a man need?). 

Their house has a balcony that looks out over the valleys and mountains that surround the village. So, it has been wonderful to spend some quality time, playing music, eating, drinking great wine, and simply sitting and watching the world go by. The realities of the world will still be there when I return, but just for a few days it has been wonderful to step off the merry-go-round and chill.

The last time I was here in Portugal, was December 2019. I presented a keynote paper at a mental health conference. It was a stay that I really enjoyed and I promised I would return the following year. Little did we know what was coming to the world in 2020. Covid-19 reached Portugal in March 2020; in the UK it was February of the same year.

Many readers will know that Portugal is part of the Iberian Peninsula and is famous for its beaches, port and great food. Possibly some people will have heard of their most famous football player, Cristiano Ronaldo. What is probably less well known is that Portugal has a very good healthcare system. In world rankings (supplied by Numbeo) Portugal ranks 24^th – the UK, 15^th. Top country in this index is Taiwan, something I wrote about earlier in the year. Last year’s World Index of Healthcare Innovation, an index based on measuring quality, choice, science and technology and financial sustainability, ranked Portugal 22^nd. The UK was 10^th. Strangely Taiwan is not part of this index.

Actually, I have never been a great fan of league tables. Both the league tables above do little to ensure that different health care systems are comparable. More importantly, such metrics tend to look only at illness services and not at measuring how the social determinates of good health and well being are addressed. And that’s where I’m at in my thinking. It’s possible to have the best acute medical services in the world, and we need them of course, but if we could do more to prevent ill health, then the world would be a better place.

So, as I’m in Portugal, let me provide you with an example or two of what I mean. Here there is a universal and publicly-funded health service. It’s called Servico Nacional de Saúde (SNS) – it is similar to what we think of as our NHS in the UK. As in the UK, most services are completely free to all Portuguese citizens. There are some charges called ‘taxas moderadoras’ which are not there to help pay for the provision of health care, but to stop people accessing services that they don’t need. If you visit your GP, you pay a fee of about £4.50. To go to your local A&E department as a non-emergency presentation, it’s £13.50. Like in the UK, you will need to pay for your prescriptions to be filled (unless like me, you are over the age of 65). Now then, here’s a thought, what about if we introduced these charges to out NHS. I’m sure it would make a difference to the ever increasing urgent and emergency care demands. I know it’s an idea fraught with issues of how to protect the truly vulnerable, but goodness I like it.

Like many countries, cancer, cardiovascular diseases and respiratory conditions are the most concerning issues in Portugal.  Reducing the risk of experiencing one of these conditions revolves around addressing both health inequality factors and life choices. My friend Keith is one of the 17% of people in Portugal who continue to smoke tobacco. He is a health care professional and understands the harm smoking has on an individual health. Internationally, smoking remains the number one preventable cause of death. The World Health Organisation report that it kills more than 8 million people a year, including 1.2 million deaths of people exposed to second-hand smoke. Smoking related deaths and illness are the number one preventable health care problem. Interestingly, last week the renowned Health Foundation, published a survey that observed only 46% of people thought the UK government were doing enough to reduce the harm caused by smoking. There is another health aspect to smoking that is nothing directly do with smoking, but is just as damaging. It is the economic impact. A packet of 20 cigarettes in the UK cost between £10 – £16.50. That is a lot of money to get diverted from household spend and, in many circumstances, it will be an additional contributor to poverty. And so, the circle of social determinants impacting on health and wellbeing turns once more.

It doesn’t have to be like this. I’m saying hats off to the New Zealand government. Two weeks ago, they introduced a new law that sets a steadily rising purchasing age so that today’s young people will never be able to legally buy cigarettes. The age limit will be raised year on year. Additionally, in the future you will only be able to buy cigarettes from specialty tobacco stores. I have seen this approach work well in Finland and parts of Australia with the selling of alcohol. In announcing the new law, the New Zealand Minster for Health, Ayesha Verrall, said: ‘Our priority in bringing this bill is protecting what is precious- our people, our whȃnau (families) and our communities’. As I sit here writing this, waiting to travel back home, I have to say, Ayesha’s words resonate well with me. We do need to keep looking for ways to promote health and wellbeing rather than continuing to just build bigger and more expensive hospital and clinics. Prevention is always going to be better than cure.        

God bless the Queen; God save the King.

Last week I got bitten by a pesky biting insect. The first I knew about it was when the back of my knee began to itch. And goodness did it itch. A perfectly formed hard lump appeared and the itch got worse. I applied all my many years of nursing knowledge to stop the itching, you know rubbing it with saliva, a drop of red wine and so on. All to no avail. In the end I decided that mind over matter was the way to go, but that itch dared me to scratch for several days before finally disappearing. I had a different kind of itch last week that tempted me once more to scratch. Not an insect bite but something just as irritating. It was the announcement that our next Secretary of State for Health and Social Care would be Therese Coffey. The almost irresistible itch was to devote this entire blog to her appointment.

But of course, events last week overtook me. On Thursday, our Queen died. Her Majesty, Queen Elizabeth II was perhaps one of the most recognisable people in the world. She was Queen for 70 years and 214 days. She was the second longest reigning monarch of all time (King Louis XIV of France reigned for 72 years and 110 days). During all that time the Queen guided the UK through a post-war recovery, family challenges, technological innovation akin to the Renaissance and enormous social change. It is worth acknowledging that as a woman, the Queen succeeded in so doing, in a world where the social order was largely determined and arranged by men. She had a great sense of duty and always discharged this with care, compassion, an interest in others, and, at times, a sense of humour. She made people feel valued and special. The Queen was a much-loved and respected person and her passing truly feels like an end of an era. Yet strangely, it doesn’t feel like the start of a new one to me just now.

I never met the Queen in person, but have come close to doing so on five occasions in my life. The first time was when I was a young Boy Scout and along with many other Scouts, I entertained the Queen at some event now long forgotten. I do remember an archery session where I had to shoot arrows at balloons fixed on targets. The second time was when my father received his MBE at Buckingham Palace and I was allowed to witness the ceremony. The third and fourth times were connected to my university career. I had lunch with the Queen (along with 100 other folk) when she opened the Geoffrey Manton Building at Manchester Metropolitan University and saw her again, a few years later, when she opened MediaCity in Salford. Finally, J and I were invited to attend one of her legendary garden parties in 2020. Sadly, we never got to go due to Covid restrictions.

Hers was a life lived well. Like her family, and as we have seen, many people across the world, I will miss not having this wonderful person in my life.

There was another woman who died last week, who although perhaps wasn’t as well known as the Queen, I wanted to mention here. Her name was Marilyn Loden. In a different way, she made a big difference to many people’s lives. Marilyn was a passionate feminist, and she was the person who first coined the phrase the ‘glass ceiling’. Some have described her as a pioneering feminist, and she was certainly iconic. In 1978, she first used this now famous phrase when she spoke at the Women’s Action Alliance Conference in New York. Marilyn was not meant to speak and was a last minute substitution for a speaker who failed to turn up. It was during this panel discussion that she talked about the struggles women can experience as they try and advance their careers in often male dominated organisations. She described how many women find it impossible to break through the ‘glass ceiling’ due to cultural prejudices and powerful organisational norms. The ‘glass ceiling’ became a phrase that resonated with women globally. It continues to resonate to this day.

Marilyn wrote many books, the first of which perhaps captured the zeitgeist of the time (1985). It was titled, ‘Feminine Leadership, or How to Succeed in Business Without Being One of the Boys’. In the US she had a positive impact. I loved the story told of Hillary Clinton, who in 2008 after losing the US Presidential race to Barack Obama said: ‘Although we weren’t able to shatter that highest, hardest glass ceiling this time, thanks to all of you, it’s got about 18 million cracks in it’. Marilyn's work led to the creation of Glass Ceiling Commission in the US. Although the commission was dissolved in 1996, the issues they tackled have been further expanded to include challenging discrimination of all forms that can be found in all walks of life. And now, globally, promoting equality, diversity and equality across societies is increasingly given greater prominence and support across all aspects of society.

Last week, in the UK, we saw the assembling of the most diverse Prime Minister’s Cabinet ever. A cabinet of ministers led by our third female Prime Minister. Unlike Hillary, Liz Truss has managed to successfully break through that highest political ‘glass ceiling’.

One of those new cabinet ministers is of course Therese Coffey. Our new Secretary of State for Health and Social Care is, at the very least, controversial. As a role model for healthy life choices, I’m not sure our cigar loving, wine drinking, overweight Therese hits the mark.  Some folk have said she also holds several prejudices. She is not keen on abortion, same sex marriages and urged those on Universal Benefit to work extra hours each week to make ends meet. And I don’t think she’s on Marcus Rashford’s Christmas card list either.

However, after the last few days where we have recognised and celebrated the consistent service, duty and leadership Her Majesty Queen Elizabeth II has provided over 70 years of her reign, the Therese itch is one I can leave unscratched. Let’s rather say thank you to our Queen, may she rest in peace, and let’s all look forward to a new era with King Charles III – God save the King.

People, resilience, hope and the need for change

Well, here we are in September. 2022 is three quarters done. Realising this, reminded me that we are around for just one time and the importance of living each day to the full. Each day we have will be different. There will be different things to see, hear, do or say. Today is day 193 of the war in Ukraine. Every day I keep all those impacted by this dreadful war in my thoughts and prayers. Friday saw an escalation of events once again. 

However, I was reminded of the need to see each day as a gift by a picture in yesterday’s Financial Times showing a group of children in Odessa painting wrecked Russian military vehicles in bright colours and patterns. 

The photograph was one that spoke to me of resilience and innocence and the importance of being a child.

September also brings with it the outcome of what has felt like a never ending process to see who might be our next Prime Minister. For different reasons, whatever the outcome and whoever becomes the next PM, the future feels just as bleak as that facing the children in Odessa. Alongside the war in Ukraine, the cost of living crisis has rightly dominated the headlines over these past few weeks. What has attracted less attention, both from the media and our politicians, has been the struggle to keep our NHS best able to deliver care safely and effectively. As September beckons the end of summer, I think many of my colleagues will tell you that the summer of 2022 has been worse than many of the winters they will have experienced.

I don’t need to tell colleagues working in health and social care what the issues are, but fundamentally the long waiting lists, pressure on emergency and urgent care services and growing numbers of people in acute hospital beds who have no medical reason to be there, are caused by two issues: workforce shortages and the absence of a comprehensive social care system.  

Vacancies in the NHS are now running at an all time high, with 1 in 10 posts currently unfilled. Without the right number of people, services cannot be provided. The same is true in social care, where providers struggle to recruit enough carers.

I was amused and irritated in equal measure last week when our latest Secretary of State for Health and Social Care, Steve Barclay, noted that there were some 53 thousand people employed in organisations across the NHS ‘of whom the majority are not providing direct patient care’. He was talking about, NHS England, Health Education England, NHS Digital and even the Department of Health and Social Care itself. I was amused by the old chestnut that we have too many managers and administrators and not enough folk in white coats, but irritated that he suggested that the 53 thousand needed to ‘streamline the administrative burden of those on the front line and not risk adding to it’.  

Why my irritation? Well, it goes like this. Politicians make policy decisions such as how much to spend on the NHS, or how many health care professional training places to commission through our universities. When they get it wrong and there is an unexpected consequence that impacts on what society expects, they look for a scapegoat to move the scrutiny away from themselves. For example, in 2015, the then Chancellor, George Osborne announced that student nurses would cease to get a bursary in 2016. It caused much outcry across the nursing profession, universities and in fact, almost everyone except perhaps the Daily Mail and Daily Express. The consequence was a 40% drop in number of applications to nursing programmes over the following few years.

We are living with the legacy of that decision now. In June of this year there were some 40,000 nurse vacancies in England. Without the right number of people, we can’t provide safe and quality services.

So, what I found really irritating about Steve Barclay’s notion of reducing the administrative burden is that politicians, (including himself and his predecessors) in looking for scapegoats, actually increase the administrative burden by asking NHS England Regional Offices to provide data and explanations as to why, for example, the waiting lists aren’t reducing. It’s a request which then gets passed down to individual NHS Trusts to come up with the figures. All of which is a huge distraction. Every day, many hours will be spent producing this information which then gets passed up the line to eventually reach the politicians. This information then appears to provide Ministers of State, the Daily Mail, Express and other right wing media with ammunition to castigate NHS provider organisations for not doing enough to get things sorted. After all, the NHS budget has been increased, so there should be more than enough money to get things sorted.

Even with additional money, though always welcome, without the right number of people, it’s difficult to see how waiting list numbers can be reduced and safe and quality services continue to be provided. The same is true in terms of both health and social care services.

Now dear reader, I don’t want you to think that my polemic here is a result of despair. Not at all. I’m proud to work in a health care system that has given more than a 100% over the past few years, and continues to do so now. I’m proud to work with folk that raise their eyes and ambitions and think about how we might transform our NHS. I’m proud to stand alongside colleagues who day after day go that extra mile in making a difference to the lives of others. That said, the challenge to bring about real change is here right now and needs addressing. Whoever becomes our next PM on Monday will need to be thinking not just about where the NHS is currently, and the winter to come, but the very future of the NHS itself.