It’s all change once again at the top, but the NHS challenges remain the same

I have long been an avid reader. I consume the written word with as much gusto as I imbibe wine. One of the most famous books of all time is one I haven’t yet read. It’s John Milton’s ‘Paradise Lost’. Actually, Milton’s epic poem is not one book, but 10 books, which together contain 10,000 lines of verse. Every word and line had to be dictated by Milton, as by the time he wrote it he had gone blind. I’m sure one day, I’ll get round to reading it. Milton was also famous for giving us the proverb, ‘every cloud has a silver lining’. It comes from his earlier work, ‘Comus’, which I’ll admit I also haven’t read yet. It is a familiar saying, and one that came to mind last week, with the news that Dr Feelgood* was removed from her role as Secretary of State (SoS) for Health and Social Care. She was replaced by Steve Barclay.

Regular readers of this blog will perhaps recall that I was rather vexed about Steve Barclay’s appointment in a blog I wrote at the end of July this year. Partly this was based on his rather strange views on health and the NHS. For example, he believes that nurses don’t need to have a degree to be a nurse, and we should be able to get the training done in 2 years not 3. You can read my argument as to why I thought this was, and is, absolute bunkum here.

Steve Barclay was previously appointed to the role of SoS on 5^th July this year. The Health Service Journal greeted the news with the headline ‘Steve Barclay is the NHS leadership’s worst nightmare’ and suggested he saw the NHS as a ‘bottomless pit, resistant to change and unaccountable’. A bit harsh perhaps. He certainly has a reputation for thinking that the NHS has too many managers. The reality is that the NHS management costs are considerably lower than most of its western counterparts.

Unbeknown to Barclay, having only been in post for just 58 days, he was to lose the role some 6 days later when Liz Truss took office. Just 79 days later, he is back as SoS once again. Things have changed for the worse during those 79 days. Ambulance services are stretched to almost breaking point as patient flow through hospitals is severely impacted by the continuing shortage of social care provision. Covid cases are once again adding to the problems of managing the ever-increasing demand for health care as well as dealing with the 7 million people waiting to be treated. The cost-of-living crisis has been made even more difficult for an estimated 8 million people who are now struggling to pay bills.

Some of these folk will be working in the NHS, and we are seeing unprecedented numbers of colleagues leaving the NHS for better paid jobs, and jobs that don’t have such a intrusive impact on family life. It matters. Have a look at this article from Torsten Bell in last week’s Observer. He acknowledged that money is an important factor (pay in the private sector rising at 6.2% compared to the public sector average of 2.2%). However, drawing on a recently published research study, other factors such as staff engagement are more powerful in terms of staff retention. Interestingly, the study also posits that when nursing staff leave, senior medical staff follow – but not the other way around!

During his previous time as SoS, Barclay had suggested that the answers to the problems facing the NHS was to hold a ‘hackathon’, which was another reason why I was less than enthusiastic about his appointment. But we are in strange times. Whilst having absolutely nothing to do with Steve Barclay, last week, NHS England’s David Sloman, (Chief Operating Officer) sent out an invitation for people to attend a Winter Improvement Collaborative event in London next Tuesday. When I say an invitation, it’s perhaps more of an imperative, as each acute trust, ambulance trust and integrated care board must send at least one executive director to the event. He did, however, say please.

The event is the first in a series to be held over a 10-week period. It is not quite a hackathon, but has similar shades of approach. Described as adopting a ‘lock-in’ style methodology, each event will see senior clinical and operational managers working through real life problems and issues facing the NHS. Real time data will be used to provide the basis for root cause analysis, leading to the co-design of improvement plans, with a single set of metrics, and which can then be adopted and trialled at a local level. I don’t like some of the language, but I do like the idea of a collective approach to generating new ideas for seemingly intractable problems. I like the idea that contemporaneous data is to be used to analyse and prioritise decisions that will result in the greatest impact being achieved. I like the idea that nothing is ‘off the table’ in gaining a better understanding of the barriers to more local decision making and action. And I really like the espoused determination to undertake this work at pace.

The outcomes from this work cannot come quickly enough. This year’s winter looks set to be the toughest one yet. John Milton went on to write a sequel to his earlier work, which he called ‘Paradise Regained’ (and yes, I haven’t read that either). There aren’t any easy or quick answers to the challenges facing the NHS, and perhaps there never was an NHS paradise. However, it’s only fair to give the new SoS an opportunity to demonstrate the leadership necessary to keep our NHS safe and secure, just as every day, colleagues continue to find ways to deliver high quality, and safe services for patients.

 

* Whereas I previously feared for the NHS under Therese Coffey’s management, now it’s my hens I worry about.

No More Turning Away - Like Kindness, Public Health Matters, Always

Last week left me struggling to describe the collective experience we witnessed as events unfolded at Westminster. I felt my descriptive lexicon was totally exhausted. Mayhem, havoc, chaotic, humiliating, confusion, toxic and very, very sad. These are all the words that come to mind when I think about the last few weeks in UK politics. My sadness is for the country and what has been done to our way of life.  I've also felt increasingly sad for Liz Truss’s husband, Hugh.

As sometimes happens, when I look at individuals for background information for my blogs, I am often surprised by the connections with my world. Hugh O’Leary’s mother was a nurse, and his father was a lecturer. He went to the London School of Economics, where he met Therese Coffey, our current Secretary of State for Health and Social Care (SoS).

I cannot begin to imagine the stress the pair of them have been under. Standing by his wife, which he has done on a previous occasion, but in different circumstances, would have been incredibly difficult. I take my hat off to him. His dignified and solid support for Liz is to be applauded. However, to be clear, I’m appalled by the damage she has wrought on the UK during her brief time as Prime Minister. As someone said last week, what has happened is unforgivable and we should never forget this time.

Equally appalling last week, was the news that Therese Coffey had recently admitted that she had illegally shared her own supply of prescription medications with friends and family. The UK Medicines and Healthcare Products Regulatory Authority confirm that it is illegal to share prescription medication with someone for whom it is not intended. She was rightly taken to task by folk on social media who described her as Dr Feelgood, with a handbag full of illicit goodies – not a good place for a minister of state to find themselves.

Her behaviour was wrong on so many levels. As are her plans to allow pharmacists to dispense antibiotics without the need of a GP prescription in order to reduce demands on GP practices. Her proposal was condemned by many health care professionals. Professor Stephen Baker, a Cambridge University international expert in molecular microbiology and anti-microbial resistance, described the proposals as ‘moronic’. He added that widening access to drugs in this way was dangerous. The overuse of antibiotics contributes to the emergence of drug resistant bacteria, and reducing the unnecessary prescribing of antibiotics has long been a central plank of UK public health policy.

In any event, pharmacists can already prescribe and dispense prescription-only medicines in some limited emergency circumstances. Likewise, other pharmacists who have undertaken further training, can practice as a pharmacist independent prescriber. Like doctors and Advanced Nurse Practitioners, with prescribing rights, they are able to prescribe medication for any condition they’re clinically competent in. Actually, both have been able to do this since 2006, when Patricia Hewitt was SoS for Health. The approach was introduced as a way of reducing pressure on GP practices. I have used this service when my repeat prescription medication is up for review, and my pharmacists has always been able to independently change my medication as necessary. I have always felt to be in safe hands.

And whilst I don’t want to be accused of hounding Dr Feelgood, her ultra-libertarian ideology doesn’t make me feel that the UK’s health care system, or me personally, is in safe hands. My favourite philosopher, Michel Foucault, when talking about the relationship between the State and healthcare argued that a doctor’s first task, before seeing the patient, and providing a diagnosis and treatment, is a political one. He suggested that doctors must first ‘begin with a war against bad government’. So, I make no apologies for speaking truth to power in my criticism of the proposed changes to current UK health care policy. I’m not the only one either.

You may well have seen Dr Dan Poulter’s stinging challenge last week, where he described Dr Feelgood’s hostility to what has often been referred to as the ‘nanny state’. Dr Poulter is well qualified to challenge the Dr Feelgood approach. He is a Conservative MP, an NHS doctor and someone who served as health minister in the coalition government (2021-2015). It seems Dr Poulter’s motivation for calling out the SoS was her opposition to banning adults from smoking in cars containing children – even though this practice was made illegal in 2015. Dr Feelgood is a smoker and has long opposed any restrictions on smoking. Making it clear that she wants to scrap previous measures to curb obesity such as the sugar tax, not introducing the smoking control plan, and ditching the health inequalities’ White Paper feels very short-sighted and, frankly, alarming.  

More smoking and greater rates of obesity will result in more chronic ill-health and increased pressure on the NHS. It is also likely to result in reduced life expectancy for many, particularly amongst the poorest groups in our communities. It seems to me that our current SoS is choosing to ignore what I think is both an ethical and practical responsibility of any government to tackle those known contributors to poor health. Individuals have a responsibility for their own health for sure, but so does our government. Foucault also observed that the impossibility of perfect health implies the impossibility of a perfect health care system. Choices will always have to be made as to what is practically and economically possible to provide in terms of health care. Ditching the UK’s evidence-based public health policy doesn’t seem to be a great choice.

I live in hope, however. We are clearly going to have a new Prime Minister by this time next week. Hopefully this will mean a new Cabinet too. If we don’t, the mayhem will continue and again, it will be you and I that stand to lose out once more. Given next weekend will be full of excited children embracing Halloween, let’s hope there will be more treats than tricks this time round.

Can we make a difference differently?

Can I just say (very loudly) how wonderful all those folk working in my GP practice are. I think the continuing sniping and complaints levelled at GPs and primary care colleagues is most unfair and uninformed. I want to acknowledge my respect and thanks to all those working in primary and community care, for all that they do each and every day. All through the pandemic, I never had a problem in accessing help whenever I needed it. Yes, sometimes that access was over the phone, and perhaps not always with my GP herself, but come on, she heads up a wonderful team of health and social care professionals.

Great teamworking is critical in effectively meeting the needs of individuals and the communities within which they live. Last Monday J went off to get her Covid booster and flu jab. I was slightly annoyed as I was originally going to get mine before her, but due to circumstances beyond my control, my appointment had been pushed back until the end of October. I was worried by the delay. Covid has not gone away. Although the numbers of cases are still very modest, 12,434 across the UK, this represents a 31% increase in the number of cases over the past week. A word I fail to say correctly, but can write, is ‘exponential’. The 31% rise is simply exponential, and it’s that thought which had given rise to my anxiety and unease.

Back to last Monday, my phone buzzed, and J, speaking from our GP practice, said, ‘get down here as they will do your booster and flu jab right now’. I didn’t need to be asked twice. Down I went and got my two jabs. J filmed it all and I was pleased to post the picture on social media. I am very thankful that I was able to get an early booster. I would recommend that all readers of this blog and all their families and friends follow suit as soon as it is possible to do so.

Now my GP practice is one of two located in our health centre. It is a fabulous place. We have a swimming pool, library, café, chemist, gym, a children’s playground and outside sports area. It’s the base for community health colleagues and houses a comprehensive multi-professional health team. It is clean, bright, airy and almost Scandinavian in design. Like many of the modern health buildings in the area it also has a beautiful glass sculpture design made by the wonderful John Ditchfield. If you are in the area his workshop and studio are definitely worth a visit.

Of course, not all health care environments are located in such modern buildings. Sadly, many hospitals and GP practices are to be found in old, expensive to run and often dilapidated buildings. Some are just downright dangerous. A report from NHS Digital, published last week, showed that it cost over £10 billion to improve these buildings and deal with every growing backlog of maintenance and repairs. When I describe some of these building as being dangerous, they really are. Nearly £2 billion of the £10 billion are for repairs which are reported as being ‘high risk’. These are situations where the need to repair or replace buildings and facilities is critical to avoid catastrophic failure, major disruption to clinical services and resolve safety issues that could cause serious injury or death.

Across England there are some 30 hospitals where the roofs are in danger of collapsing because the reinforced concrete they are made of is beginning to deteriorate and crumble. Some of these hospitals are now operating with steel props in place to hold up the roofs. Perhaps ironically, the West Suffolk hospital, which provides services in the parliamentary seat of the current Secretary of Health and Social Care, has a high-risk backlog maintenance bill of some £62 million. During 2020-2021 there were 10 safety incidents related to critical infrastructure risks at the hospital.

Mind you Cuppacoffee was conspicuous by her absence last week, perhaps she was having a sly cigar behind the DHSC bike sheds. In any event she needs to look at the amount of money currently allocated to deal with these concerns next year. Unless there is a change, the allocation for backlog maintenance is just £1.4 billion. This is just 14% of what is actually required. And I guess we can kiss goodbye to the 40 new hospitals promised by the previous Prime Minister. My own hospital, which is landlocked and has many buildings that are not fit for contemporary health care, did submit a bid for one of these new hospitals. The original estimate was that it would cost at least £500 million to build. Given the other financial pressures facing the government, I grow less confidence that we will get our new hospital any time soon.

However, whilst I think we will always need hospitals of some sort, possibly becoming more specialist, I do believe that we could do something different. Where I live, we have a lovely little hospital, the Blackpool Victoria Hospital. The name perhaps provides a clue as to the state of some of the buildings. The original hospital was opened in 1894, moving to its current location in 1933. Interestingly, its original location now has a state of the art urgent care centre, complete with another John Ditchfield glass art installation. I have been there as a patient, and the service and facilities are first class. Instead of building more large hospitals, perhaps we could build more of these types of urgent care centres. So much more health care could be provided in services such as these and my GPs health centre, and frankly, elsewhere in the community.

If the Covid pandemic gave us anything, it was the courage to do things differently, do things together and do things at pace. Maybe out of the political and economic turbulence we are once again facing, we can find that transformational vision and energy again to make a difference differently. 

What an extraordinary week!

Last week was an extraordinary week in many ways. For example, the trial started of Lucy Letby at Manchester Crown Court. If the name is not familiar, she is the nurse accused of murdering seven babies and attempting to kill 10 more while she worked on a neonatal unit at the Countess of Chester hospital back in 2015. Lucy denies all the charges and the trial will take up to six months before we get to a verdict. It will be a long and distressing period for the families of those involved whatever the outcome.

Then there was that extraordinary outburst from Miranda Hughes, a nurse working in the independent sector. On the Jeremy Vine television show she declared that ‘if you voted Conservative then you don’t deserve to be resuscitated by the NHS’. Although Miranda works in the private sector, as a registered nurse, she is still bound by the Nursing and Midwifery Council’s (NMC) Code. The Code sets out the professional standard of practice and behaviour for nurses, midwives and nursing associates. The Code is very clear that nurses on the NMC Register must promote professionalism and trust at all times. She has been sacked by the company she worked for, and I’m sure the NMC will investigate and take action if that is felt to be appropriate. Her 15 minutes of fame will cost her dearly.

And of course, there was this year’s Conservative Party Conference. Possibly more circus than conference. Good old Nadine, who can always be relied upon to say something extraordinary, did just that. She appeared to be telling the Prime Minister that now was the time to call a General Election. Good old Therese gave a Masterclass in how to cure insomnia, as her conference speech sent half her audience to sleep. As there’s me thinking coffee usually wakes people up. Finally, there was Liz (neither old nor good) who, blaming everyone else for the UK’s troubles, seemed to be in complete denial over the fact that the Conservatives have been in power for the last 12 years. Anti-growth coalition indeed. The whole spectacle was like a ‘Have I Got News For You’ boxset. It was just as funny, but not funny at all. Truth be told, it was heartbreakingly sad.

But there were, for me, two extraordinary events last week which really did make my heart soar. The first was this year’s Annual Members Meeting (AMM). This is a statutory requirement for all NHS organisations, with an Annual Report and Accounts laid before Parliament each year. The AMM is an opportunity to share with the Council of Governors this report, and also to celebrate some of the improvements and service transformations achieved in the past year. Why was it extraordinary? Well, it was the first time in over three years that we could invite all the Governors and Members into the Trust for a face-to-face meeting. Over 60 turned up on the wettest and windiest afternoon imaginable. We splashed out and bought a new lectern, for the occasion, tastily resplendent in NHS blue. Now I love a good lectern from which to speak to an audience, and last week was no exception. The presentations were great and the question and answer session, lively, informative and dare I say it, fun too.

The highlight of the afternoon for me, was a special presentation made by one of the consultants from our Pain Service, David Crabtree and his colleague Esther. It really was a masterclass on what a difference involving patients, right from the start, can have when thinking about service transformation. He had a great illustrative example: he knows that if you give a group of patients £100,000 to design a clinical service, they will do so and never spend all of the money. The new service will be more effective and efficient. Give £100,000 to doctors and nurses to do the same thing and they will spend every penny and come back for 10% more. The likely outcome will be a new service that is neither effective nor efficient. His was a salutatory message about the value of consumer involvement in transforming healthcare services.

The second event was a slightly grander affair. Think ‘Strictly’ 2022. The occasion was our ‘Making a Difference’ awards night, and we held it in the magnificent Stockport Town Hall ballroom. Interestingly, the ballroom was used as a hospital during WW1, and a home for overseas refugees during WW2. 

The evening was hosted by Karen James OBE, our Chief Executive, and me. It was wonderful to also have the BBC health correspondent Dominic Hughes, as our guest of honour to present the awards. Although there was no ‘official’ dress code, most people arrived dressed for the occasion. I had to go out and buy a new tuxedo, as since joining the Trust, my waistline seems to have expanded somewhat (we do have delicious award-winning food served in our staff restaurant).

There were 11 award categories which attracted over 100 nominations. Whilst all the nominations represented exceptional achievement, the eventual prize winners were extraordinary. The award ceremony part of the evening was electric with excitement, and there was a real sense of belonging and being there for others. We absolutely acknowledged that whilst the 300 people in the room were able to enjoy the evening, there were another 5,200 colleagues not present, many of whom would be collectively equally making a difference for others in our hospital and community services.

The evening was a huge success. We enjoyed a great meal and I enjoyed sharing a drink and conversation with some amazing colleagues, some of whom I was meeting for the first time. There was a bit of a disco too. Highlight for me was a special award, made to someone whose nomination didn’t quite fit the other categories. This was a colleague who was completing a sponsored charity event when he came across someone who had collapsed and suffered a cardiac arrest. He put into practice the resuscitation training he had undertaken at work. Delivering chest compressions, and using a community defibrillator, he saved the person’s life. What was remarkable was that this particular colleague didn’t work in a clinical setting, but was actually our electrical maintenance manager. As he approached the stage to receive his award, the whole ballroom rose to their feet and gave him a standing ovation. He was, and the moment was too, totally extraordinary.   

The importance of women in health care – not quite a panoramic view

Last week I had a 38 year flashback moment. It was the time when I first arrived in Manchester. I had got a job at the first NHS forensic secure unit for adolescents. It came at a very turbulent time in my life. Despite my personal troubles, I was going to take up what felt to me to be a dream job. As the Nursing Times described the opportunity at the time, I was going where no RMN had gone before. And I was. There was no rule book, procedures or other services to copy. We had a blank piece of paper and had to start from first principles. I loved those first few months. I went and spent time at various other forensic institutions, from a special hospital near Ormskirk in Lancashire, a prison in Manchester, to a private hospital in Northampton. The service I arrived at was a medium secure service providing treatment and care for troubled and at times, troublesome children and young people. It was a mixed sex unit, which often gave rise to issues as to whether a young person’s behaviour was ‘normal’ adolescent behaviour or as a result of their mental illness. We paved the way for the development of adolescent forensic mental health services nationally. It was a privilege to be part of these hopeful new beginnings.

Six years later I had become the Service Manager for all the regional specialist mental health services located at Prestwich hospital; a hospital managed by Salford Health Authority. One of the services for which I had responsibility, was the adult forensic services at The Edenfield Centre. This was (is) a Medium Secure Unit. Patients came here from special hospitals (High Secure) or from Low Secure Units, or from within the criminal justice system. All those years ago, it was very much the jewel in our crown. The service had a wonderful reputation for compassionate and person-centred care. Unsurprisingly, experienced colleagues working within the field of adult forensic services had been hugely supportive and immensely helpful as we set up the adolescent forensic service.

So, it was great sadness that I watched last week’s Panorama programme. It featured an undercover reporter’s account of the three months he had worked on one of the clinical areas in the Edenfield Centre as a Health Care Assistant. He had worn a hidden camera with which he recorded some very distressing and totally unacceptable incidents of abuse, neglect and cruelty. Much of this behaviour came from qualified mental health nurses. It was a difficult programme to watch. All those featured have been suspended and face both disciplinary action and probable police investigation. I no longer know many of the nurses working there these days, but I do know the Chair, some of the Non-Executive Directors and a couple of the Consultants. All are highly shocked by the revelations and deeply committed to ensuring safe care is being provided. There was no pre-screening of the programme, so I think it will have been very difficult to support colleagues and patients who would have watched the programme and have been affected by what they saw.   

It certainly wasn’t a great day for mental health nursing or mental health care. 

And last week it was the monthly NHS England Regional Office meeting with Chairs and CEOs from across the North West of England. It was an equally sobering meeting in the main, a meeting where good news was hard to find. However, there was one agenda item that really caught my eye and made me think. It was a presentation by folk from the Liverpool Women’s Hospital. The presentation focused on their response to the recently published Women’s Health Strategy for England. Now to be perfectly honest, this strategy passed under my radar completely. I’m not sure whether August was a busy month for me, but I was not sighted on this document at all. You can read the strategy here. It’s a mere 132 pages long, but it will take a lifetime to deliver what’s needed to address many of the issues.  

There are some basic facts that are irrefutable. Women live on average longer than men, but they spend more of their lives in poor health. Women make up 51% of the population but historically the health and care systems have been designed for men by men. Looking at the NHS workforce, 77% are women. Despite the fact that 69% of all posts at 8c – 9 (middle to upper management grades) are filled by women, women do not feature prominently in research, and in the education and training for healthcare professionals. They are seldom included in the design and development of healthcare policy. Only 47% of the most senior roles in the NHS are held by women.

At a national level, the same is true. During the time I have been an active contributor to health and care services in England, (some 40+ years) we have had 16 Secretaries of State (SoS) for health and social care. I have met many of them. Of these, and including the latest SoS, there have only been 3 females to hold the post. So perhaps it’s not difficult to see why women’s health and contribution to wider health care has not been prioritised. The consequence has been a complete failure to place women at the heart of health services. Arguably this has had a huge impact on how we address access to health and social care services and how we address the destructive impact on health inequalities.  

The Women’s Health Strategy adopts a ‘whole life course’ approach to issues facing women today. It focuses on gaining greater understanding of the changing health and care needs of women and girls across their lives.  In so doing, the aim is to both identify the many stages, transitions and opportunities during a women’s life span, where good health can be promoted and where preventive measures can be put in place to help ensure positive health and wellbeing. In a sector mainly populated by women, we simply cannot ignore the notion of recognising what a women-centred service might mean in addressing inequalities close to home. Not to do so risks the NHS featuring in a future Panorama programme, and worst still, the prospect of an ever-deteriorating NHS service for all.