We are our choices, sometimes*

Many years ago, I used to spend many a late night/early morning hour in what was the original Covent Garden market. It was a fabulous place. The market sold fruit, vegetables and flowers to wholesale suppliers, and through the whole night/early morning there was constant noise, bustle, and movement. Sadly, the fruit and vegetable market is no longer there. It was closed in 1974, and the market was moved to a purpose-built New Covent Garden Market near Battersea in south-west London. These days the original marketplace has been turned over to cafes, pubs and the usual selection of shops that sell things you don’t need but feel you ought to buy. There is a small bijou craft market that opens from Tuesday to Sunday selling handmade jewellery, ‘one off’ collectables, crafts and paintings. It is lovely, but lacks the atmosphere of the original market.

Although today, I can’t recall what the fascination I had for the market was, one of the things I do remember about those visits was the stalls selling hot tea in large mugs and bacon rolls. If I close my eyes, I can smell the burning fat and that distinct fried bacon smell. I didn’t eat the bacon rolls, I was already a vegetarian by then, but I would have a fried egg roll; a treat I still like today.

All those years ago, my choice of late-night snack might have proved fortuitous. Updated research findings published last week, from a study first undertaken in 2016, have found strong evidence that eating just 50g of processed meat every day such as bacon (and 50g is about two rashers) increases the risk of stomach cancer. Each year, over 7,000 people are diagnosed with stomach cancer in the UK, leading to around 5,000 deaths. But it is not just bacon. In the report, processed meat includes ham, salami, hot dogs, and some types of sausages. Processed meat has already been shown to have a link to bowel cancer. If you are obese, and consume 2 or 3 alcoholic drinks each day, the risk of stomach cancer increases substantially.

I was pondering this last week as I stood in line at our staff restaurant breakfast counter. It was laden with the usual full English breakfast selection of foods. Eggs, baked beans, hash browns, mushrooms, fried tomatoes, and piles of sausages and bacon. I wondered if we, the Trust, were right to be selling food that might cause harm to some people. However, like many things in life, what you eat is often down to personal choice. Perhaps that is not true for everyone these days. The cost-of-living crisis is increasingly forcing people to make other choices about what they can afford to cook and eat each day. Some of these alternative choices might also have a detrimental impact on their health.

My interest was drawn to the complexities of some of the choices we are increasingly being asked to make. Last week, for example, I also noted the recent approval from the European Parliament that requires all listed companies to ensure that by 2026, 40% of Non Executive Directors positions are filled by the underrepresented sex; in EU terms, this means women. If the ruling is applied to all Board Directors, then 33% must be women. But of course, women are not necessarily the only under-represented groups on boards.

Whilst the ruling doesn’t directly apply to us at the hospital, I wondered what impact such a ruling might have on our recruitment decisions and how easy it might be for many organisations to comply with the ruling. In our Foundation Trust, we have just recruited another Non Executive Director (NED). Although there was great interest in the opportunity (we had 36 applications) there were only 8 women who applied, and of the men, 20 were white, and mainly from older age groups. We did appoint the best person for the job, who just happened to be a woman, but the decision we took was based on her skills, experience, knowledge and to be honest, her fit with the rest of the Board.

Thankfully, she will be joining an already diverse Board. There are 10 women, including our Chief Executive, and 6 men on our Board. 3 of our Board members come from black and minority ethnic backgrounds. We are also blessed with a wide range of ages, sexual orientations, and physical abilities. All of the directors were appointed on their merits and not because we were trying to comply with some form of diversity dictat. I understand the energy and positivity that can come from building a more diverse and inclusive workforce, but I’m not sure setting quotas is the way forward. I think it could lead to some very perverse choices being made.

It doesn’t  need to be like this. One of the programmes within our equality, diversity and inclusion strategy actively encourages and supports colleagues to grow their careers whatever their background, gender, age or race. It will take time to bring these folk through a system that has largely worked against most people seeking out such opportunities. If you don’t believe me, try making an application to become a NED in your local health care organisation. These days, as J has already found out, I can almost guarantee it will be a challenge to get past the shortlisting process unless you have previous NED experience or have held a very senior role somewhere. And that can’t be good for any organisation.

My thoughts wandered from bacon sandwiches and Boards of Directors to wondering whether the NHS as an organisation will soon find itself having to make difficult choices. Without a massive transformation in the way health and social care services are provided, similar to that seen during the pandemic, demand will eventually overrun capacity. If that happens, I wonder who will be making the choices on what services are available, and to whom.

But let’s end on a more positive note. The same research that noted the link between bacon and stomach cancer, also reminded us that eating citrus fruits can reduce this risk somewhat. So always remember to add both a slice of lemon and lime in your G&T.

*With apologies to Jean-Paul Sartre, who of course also said, that not making a choice is also a choice.

Popping out to the resilience store

The worst queue I never stood in was on my arrival at Karachi airport. The customs/security hall was huge and filled with literally thousands of people. The flight I had arrived on had been 11.5 hours long. Although I had travelled with Emirates on that occasion, I hadn’t travelled business class. So I arrived tired and very much out of sorts. I was there as a guest of the Sindh Institute of Urology and Transplantation. Thankfully they had come to the airport and rescued me, swooshing me through the customs at breakneck speed. They simply circumvented the queue. I was very grateful.  

The worst queue I ever stood in was at Tel Aviv airport. We were returning from a pilgrimage across Israel, and traveling just before Easter. The queue was so long it snaked almost out of the departure building. It was hot, people were fractious, anxious about missing planes, hungry and thirsty too. It took over 3.5 hours to get to the check in desk. We got there some 30 minutes after our plane was meant to have departed. They held the plane. I was the last person to board. J was most impressed.

Now you may be asking why I’m telling you about these two experiences. Well, there is a reason. I spent a lot of time standing in a variety of different queues last week. Surprisingly, I was the epitome of patience. Each queue provided me with time to reminisce over similar experiences. Each experience added to my ability to just be patient. My patience might have been also partly due to my reading of the entire Jack Reacher collection of novels over the years. For those not familiar with the books, Reacher has a laid back approach to life. Things will either turn out right or they won’t. Whatever the situation, hope for the best, and prepare for the worst. I’ve found it a useful way to navigate life. Control the things you can, and go with the flow with the things you can’t. In part, it’s how I developed my ‘resilience store’.   

You may not have heard this term before. My long time co-author, Professor Sue McAndrew, and I first used the term in a chapter we wrote for McAllister and Lowe’s book ‘Nurses making a difference: strategies for empowering your practice’ way back in 2011. Our chapter looked at how nurses might best develop their resilience in dealing with the challenges of practice. And goodness, the last few years have proved to be the most challenging many nurses have ever experienced.

Last week, this was something I had a conversation about with a couple of my nursing colleagues as we stood in a queue waiting to get our buffet lunch. My colleagues shared with me what frontline practice had been like for them during these past couple of years, and what they and their colleagues were doing to deal with the impact on their wellbeing as they addressed these challenges each day. Resilience was an attribute they were proud they possessed.

The occasion was one of our Long Service Award ceremonies. We were in the company of 70 colleagues who had each worked in my hospital for at least 20 years. Across the Trust we have 250 colleagues from all areas who have all also worked for 20 years in the NHS. Collectively this represents some 5,000 years of service to the NHS. I was impressed and humbled in equal measure. It also reminded me of my age. I had also spent 20 years working in the NHS, then 21 years in higher education, including nearly 10 years as Dean of a very large School of Health, before returning to the NHS 4 years ago as a Non Executive Director and Chair of a large acute Foundation Trust. Whilst I have lots of stories from these years, it was simply amazing to hear each of my colleagues’ stories. The NHS is a wonderful institution and, it’s the NHS family that makes it so. We should keep fighting for its continued future as a ‘free to access’ public service.

Resilience and fighting for the NHS’s future were also key focuses of this year’s NHS Providers annual conference. The conference was held in the wonderful city of Liverpool, a special place for J and I. Over the two days, there were plenty of queues of course, mainly for food and drink. The theme resilience was explored through the lens of all aspects of health and social care. So, there were often conversations about people, but also of services, buildings, technology and partnerships. Protecting our NHS people was very much the number one priority. Both Wes Streeting (Labour) and Steve Barclay (the other party) spoke. I can’t say I was impressed with either. As I’m steering clear of politics, I will leave it there. A 17% pay rise for nurses? Hearing from them both, I don’t think that will happen.

I was, however, impressed by one of the sessions I went to that explored ways of promoting greater equality, diversity and inclusion in our organisations. There was much that I took away to ponder on, but one of the standout take-home messages for me was the concept of ‘brave spaces’. This was a concept posited by Edgar Schein in his book, ‘Humble Inquiry’ (worth a read). It looks at the development of both ‘safe spaces’ and ‘brave spaces’ in enabling colleagues at all levels in an organisation to gain a voice. This is a voice that might challenge, be critical, pick up on unacceptable practice or behaviours and, of course, raise new ideas. We may have the freedom to speak up, but often this can be very difficult. Feeling safe and being invited to be brave might just be the way to give more people a voice.

The last queue from last week was the bittersweet one my mother and father now find themselves standing in. My mother is increasingly living with the ever encroaching impacts of dementia. Up to now the only support they have received has been from family. Now both health and social services have got involved and they are in the system. But like most queues, there is likely to be a long wait before they see any action. Sadly, I feel their resilience store is almost exhausted.

Look who's talking

It would be difficult to write this week’s blog without commenting on the historic decision taken by many Royal College of Nursing (RCN) colleagues to take industrial action. It is something I’m slightly hesitant to do. Last time I blogged about colleagues taking industrial action, (12 years ago and not nurses) I was trolled unmercifully on social media. However, I will come back to the RCN outcome in due course. But first, let’s talk about a lady called Kelsay Irby. She is a nurse. In fact, she is a Charge Nurse working in a busy Emergency Department. On the 8th October this year, Kelsay was working an evening shift and there were over 50 patients in the ED Waiting area. Unfortunately, Kelsay only had half the staff she should have had, and the situation was quickly getting out of control.

Whilst the triage nurse on duty was doing a great job in prioritising patients by need, there was limited oversight of those patients in the waiting area whose conditions may well have started to deteriorate due to the long wait. It was a desperate, but perhaps, not too an unfamiliar situation. In desperation, Kelsay rang the emergency services for help and was connected to the local fire and rescue services who agreed to come out and help. Up came a fire tender with a crew trained in emergency first aid. They were able to re-take basic assessments and monitor the patients, allowing the ED staff to concentrate on those in most need. Eventually the ED returned to normal.

As you might imagine, Kelsay’s decision hit the news big time. But you may have missed the story as Kelsay works at the St Michael Medical Centre, Washington, in the US. Could something similar happen here in the UK? – I guess so. Last week, there were reports that the armed forces could be called in to fill the gaps if nurses take industrial action. Indeed, during the pandemic and last winter we had a small group or service men and women who worked in a variety of different roles in my hospital – and they did a great job! It’s an interesting situation.

Likewise, so is the possibility of industrial action. I would say right from the start that nurses deserve to be rewarded fairly for their work. Whilst many folk are attracted into nursing as a profession, I don’t subscribe to the notion that nursing is a vocation. It is a highly skilled profession. The education and training required are tough and expensive. And that is part of the problem. There aren’t enough nurses coming into the profession to replace those leaving, and this chronic shortage of nurses results in an unfair burden on those remaining within the profession. As Dean of a large university school of nursing I well remember my disbelief on hearing that from 2016 the bursaries student nurses received would be stopped, and that they would have to start paying for their university courses.

The decision saw student nurses applications fall dramatically. In the first and subsequent years, by nearly 40%. In 2020, the NHS Learning Support Fund was introduced. This was available to students starting their programmes in 2021. This package of support provides upwards of £8,000 a year as well as help with travel and accommodation costs while on clinical placement. The money does not have to be repaid. Students still have to pay the £9,250 a year course fee. Even with this most welcome support package, I think it will take some time before it provides the incentive necessary to significantly increase student numbers. Across the UK there was an 8% increase in student numbers in 2021. In England this meant an extra 20,930 students were recruited. In the same year just over 25,000 nurses left the profession. The students won’t join the qualified nurse workforce until 2024.

There aren’t many easy solutions. The pandemic exhausted many nurses. The cost of living crisis is hurting many more. However, the claim for a 17% increase in salaries (estimated to cost £9 billion a year) seems unlikely to be achievable. Something different in terms of an approach is required Removing the requirement to pay university fees would be a start. Likewise, writing off the education costs of students who started their training in 2016 but who will still be paying back their student loans today feels like a good idea. Symbolically, it would demonstrate the value of the nursing profession to society. Symbolically, clapping for carers doesn’t remotely have the same impact.

Of course, whilst nurses are important, they are part of a wider multi-professional health and social care team. Whatever eventually gets settled as a pay award, the impact will spread through this wider team like that famous lager that reached parts others couldn’t. Probably beyond too, certainly in the public sector. Currently, there are some 1 million other healthcare workers, from porters, radiographers, maintenance workers, doctors and so on, whose unions are all currently balloting their members over whether to take industrial action as well.

I do not blame them. All healthcare workers, whatever their profession, trade or background should be paid a fair salary for their contribution. Sadly, I don’t think calling for strikes and a large pay award will, on its own, be a sufficient basis to reach a settlement. It doesn’t have to be like this, all we need to do is keep talking*. I strongly suspect that money will not be the ‘silver bullet’ the RCN might consider it to be. Sooner or later there must be a conversation that takes a broader view of the issues other than the percentage size of any pay award. Over the coming weeks and months, it is going to be critical that all the parties keep talking. The future of our NHS, as we know and value it, is very much at stake.

*Inspired by our Pink Floyd concert last week, I thought their song ‘Keep Talking’ from their album The Division Bell seemed somehow appropriate.

May you stay Forever Young – caring for our children and young people

Billy, our parrot loves the blues. Whenever we ask Alexa to play some blues, he is in seventh heaven. He whistles along and is the best blues-playing parrot I have ever encountered in all my life. Billy is now 31 years old and has travelled the length and breadth of the UK with me. So last week we played some blues that really made him come alive – it was Bob Dylan’s recent album: ‘Rough and Rowdy Ways’. If you haven’t heard it, you can find it here on YouTube. I would recommend a listen. For younger readers, Bob Dylan is an enduring music icon from the 60s. One of the first things I learnt to play and sing on the guitar was ‘Blowing in the Wind’. Dylan wrote this classic in 1962. In 1994, the song was ranked by the magazine ‘Rolling Stone’ at number 14 of the 500 greatest songs of all time.

Its three chords certainly opened up a whole new world for my guitar playing over the last 50 odd years of playing and enjoying music. From a folk club in downtown Swansea in the 70s through to a balcony in Portugal’s mountains in 2022, and everything in between, I have continued to get great pleasure in playing my guitars and singing along to some classic songs. It’s safe to say that J and I love live music. She plays the piano, and I could listen to her play all day. But what we like most of all is going out and listening to live music. We have done this all over the UK and beyond.

And that’s what we did last Wednesday. We fought our way through gridlocked traffic that is Manchester’s norm these days, parked up and joined the queue to get into the Apollo concert hall. We were there to see the great man himself. At 81, Bob Dylan had decided to add an additional venue to his current Rough and Rowdy Ways UK tour. Ironically, we had unsuccessfully tried to get tickets for other concerts across the UK. When last week’s additional concert was announced, the tickets sold out within minutes of being released.

Dylan looked frail. He no longer played the guitar. He did, however, play some mean piano. There was no video backdrop, flying pigs, smoke or dancing girls. It was a straightforward dimly lit stage with Dylan and his band playing all his new music from the Rough and Rowdy Ways album. His voice was strong, but how he remembers all the words to songs that can be 9 or 17 minutes long is beyond me. For a couple of hours, it was blues music heaven.  Driving back through the still gridlocked Manchester traffic, was motoring hell.

Of course, Bob Dylan is someone from my youth. He was part of my rebellious period during adolescence. His songs of protest became my songs of protest. Although at the time I started smoking* and drinking, and on occasions, probably acting up. In all likelihood, my rebellious adolescence was rather tame. Which is just as well. During the first two decades of a person’s life course, we not only learn the most, but develop values and behaviours that shape our adult life. In some respects, this is why looking after our young people during this period in their life not only benefits them, but the rest of society too. Sadly, this is not always the case.

Last week, the British Medical Journal (BMJ), in collaboration with the Partnership for Maternal, Newborn and Child Health, brought together a collection of research-based papers on adolescent wellbeing. You can find the collection here. It’s a big area to go at. In their introduction, the BMJ notes that there are 1.2 billion adolescents (young people aged 10-19 years old) in the world. They represent 16% of the world’s population, and 23% of the population in low income countries. However, they are a group of the population who often receive limited attention and resources from global initiatives such as universal health coverage and sustainable development. The Royal College of Paediatrics and Child Health (RCPCH) have long called for action on reducing poverty and inequality, both of which impact upon a child’s future, and can lead to health inequalities in later life. As well as prevention, delivering early intervention services to families in need not only reduces the overall burden on the NHS, but makes good economic sense too. It’s estimated that for every £1 spent in this way there will be a return of £4 to the economy. This ratio will rise over time if the investment is made when folk are in the childhood and youth.

We are also at an interesting stage of transformation as the new Integrated Care Systems pass their first 100 days mark. The requirement to collaborate and integrate must include professions, agencies and communities outside of the traditional providers of health and social care. This is particularly so when considering interventions that support the wellbeing of adolescents and their families. Young people are not on some kind of conveyer belt to becoming an adult. However, supporting and investing in their wellbeing is likely to result in an adult population best able to meet the challenges of a rapidly-changing world. And goodness do we need them to be able to do just that. Our work today will help them live fulfilling, creative, resilient and confident lives in their tomorrows. In that sense, they are our future too.

But for tonight, J and I will be going back to the future. We are off to the Winter Gardens to see ‘Wall of Floyd’, a tribute Pink Floyd band, a group first formed in 1965. It’s only rock and roll, but we like it.     

* I haven't smoked for many years now!