Every day the clock resets - thinking about the changes we might make

Yesterday, we moved the clocks an hour forward. It’s British Summer Time. When I worked shifts, it was a prized night shift to try and get. These days, it simply means a slightly earlier start to the day. What is different is that most of our clocks adjust themselves automatically. The cooker and one wall clock are the only ones that don’t. I can just about understand how my phone and laptop change the time, but my car doing the same thing is slightly baffling.

I’ve been thinking about the nature of change a lot this past week. Lots of possible reasons, I guess. For example, every couple of days I do the ‘cabbage run’. In the winter time, J likes to give her goats a cabbage each day. They get fresh hay and a goat mix, but rightly so, she likes them to have fresh greens. In the summer, I go hedge trimming and bring home sacks of lovely greenery for them. Anyway, the ‘cabbage run’ is a 1 km walk to Aldi (there are other supermarkets available), and a 1 km walk back. 

Last week while collecting the cabbages, I walked up and down the central aisle (where there is always something to buy that you didn’t know you needed) when my eye was drawn to what looked like flat bottles of wine. They were indeed flat bottles, holding the same amount of wine as ordinary bottles, but where the weight was 84% less than glass bottles. I was intrigued, and bought a few!

Coming home I poured myself a glass, and found the wine was quite drinkable. What an innovation, a change for the better, just like when screw caps replaced corks. That was a change that some folk thought was a change too far. I didn’t, and just like the screw caps, I welcome this latest change. In the summer time, we often pack a rucksack with a picnic and bottles of wine and go and listen to the live music in our local park. These new plastic wine bottles, as well as being much lighter, won’t run the risk of being smashed along the way either.

Some changes are cyclical in nature. We live just north of Blackpool. Like many other coastal and seaside towns, Blackpool has had to reinvent itself. The days when folk from across Lancashire and Greater Manchester came for a week or two in a guest house have long gone. Back in 1894 when the famous Blackpool Tower was first opened to the public, the resort would often get as many as 50,000 visitors each year. By 1937, more than 10 million visitors came to Blackpool! During the 1960/70s visitor numbers went into decline, as cheap Mediterranean holidays gained in popularity. However, post-pandemic there has been a resurgence in its popularity, with record numbers of visitors to the town, there were over 20 million visitors in the year 2022-23.

The ups and downs of the Blackpool tourist industry continue to change, and, at the moment, I think for the better. Last week, Blackpool was named as the most affordable and popular ‘staycation’ destination to visit this year, based upon research undertaken using Google and TikTok data. Ironically, given the changes to Blackpool’s tourist industry, this situation results from more people considering ‘staycations’ over foreign holidays, as a way of saving money and avoiding the stress of flying.

Whilst for many people, Blackpool might be a great place to visit and enjoy a holiday, living here isn’t always so great for many people. Blackpool contains eight of England’s 10 most deprived wards. It has a lower life-expectancy than that of people living in Angola. Life expectancy is one of the key indicators of health across a population. It is usually measured as being the average number of years that a newborn is expected to live when applied across current mortality rates. In Blackpool, the life expectancy for women is 79.00 and for men, 73.4 years. Both these figures are way below the national average, and the gap continues to grow.

Not only do folk in Blackpool live shortened lives, they also spend a smaller proportion of their lifespan in good health and without disability. As with other parts of the UK, health inequalities are a large factor in making this a difficult situation to resolve. There are high levels of smoking, obesity, alcohol and drug misuse, all overlaid with other social determinants of poor health, including poor housing and limited employment opportunities. Blackpool also appears to be a fairly dangerous place to live. Last year, it was the second worst town in Lancashire for criminal activity. The most common crimes during 2023 were violence and sexual offences. Blackpool’s least common crime is bicycle theft. Changing this picture will involve decisions and choices that individuals make, but some will need Government support and funding. Don’t hold your breath though.

Some things don’t change. Last week, I was able to visit some of our Health and Justice Service colleagues working in prisons around the North West of England. I visited two very different male prisons and came away mightily impressed with what I observed. Great care, compassionate approaches being provided in a person-centred way, but in a context that was uncompromising about security and safety. What did I see that made me think some things never change? Many of the men knew little about their own health journeys and when assessed would more often than not say ‘I will need to ask my mum; she will know’. This was even true of a prison officer suspected of being in contact with someone diagnosed with measles. When asked if he had received the MMR vaccination, he responded by saying he didn’t know, and ‘would need to ask his mum’. And yes, I bet my mum would know how to reset that clock on the cooker too!

Thinking more about care, compassion, and empathy

Two of my favourite ways of helping people think through an issue, problem or idea is to say either ‘let me reframe this’ or ‘let’s change the narrative’. They are slightly different approaches, but can lead to the same outcome. The reframe approach is useful in a 121 conversation; changing the narrative works well with a wider discussion. Both can help shift a mindset. Reframing can help a person see a situation, issue, or relationship from a different perspective. The ‘frame’ in which the person views a situation, issue, or relationship, will determine their view, and often their behaviour.

A month ago, J and I went to look at the wonderful annual display of snowdrops at Lytham Hall. For a few weeks, sweeping drifts of snowdrops cover much of the woodland grounds of the hall. Every so often was to be found a picture frame set on a post, through which you were encouraged to take the best possible photos of the snowdrops. It was a great idea, but eventually these were the only photos we took, and perhaps we lost sight of the other wonderful things that were there to be seen.

Narrative is similar. It provides a choice of what events to share and in what order to share them. In so doing, the narrative become a specific representation of the story, rather than the story itself. Re-ordering the events will result in creating a new narrative of the same story. The use of narrative in some circumstances might give rise to the accusation that the ‘true story’ is being hidden. I don’t agree with this view. I think changing the narrative doesn’t change the ‘true story’, it’s simply that a narrative will often convey the truth of a story indirectly.

Last week Mel Stride (the Secretary of State for Work and Pensions) was attempting to change the narrative around mental health and employment. The prevailing narrative has been around nurturing and supporting folks’ mental health and wellbeing. What Mel Stride was challenging was the idea that whilst it is good that society has generally taken a more open approach to mental health, perhaps we are in danger of over medicalising the normal everyday challenges we all face. His concern was that people were now ‘convincing themselves they have some kind of serious mental health condition as opposed to the normal anxieties of life’. He was saying this in the context of the rising UK benefits bill for people signed off work because of a mental health problem.

There are 2.7 million people not working because of health problems. One in three 18 – 24-year-olds (Generation Z) now report they have or are experiencing a common mental health problem. One in five 18 – 24-year-olds with mental health problems were unemployed and workless or ‘economically inactive’, as the jargon puts it. Whilst this is not a situation anyone would like to find themselves in, it is also not good for society economically or socially. Which is why Mel Stride was attempting to change the narrative around what mental health might actually mean.

Whilst I don’t agree with this Government’s proposed reforms to the welfare system, I do think there is a need to perhaps revisit how mental health and wellbeing are conceptualised. We all have mental health.  We don’t all have mental illness. Yet if you were to consider the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), originally published in 2013, as being the absolute authority on what constitutes a mental illness, then perhaps we all do.

I have long argued that the DSM-5 lacks validity, and is often based upon evidence not underpinned by empirical research. At its last revision (which took some 10 years), some really challenging additions were to be found that reframed familiar everyday behaviours and experiences. For example: Disruptive Mood Dysregulation Disorder (what my Mum would describe as us children getting a strop on); Video Game Addition, a psychological addiction to playing internet games (two of my grandchildren visited yesterday and like many young people, were constantly on their mobile phones playing such games and watching video clips); Minor Neurocognitive Disorder (I have this! Going upstairs for something and then getting there and not remembering what you came upstairs for). Binge Eating Disorder and Nicotine Dependence Disorder were also additions that illustrate how far pathologising everyday life has come. All of these ‘mental disorders’ have their respective recommended treatment approaches.

Changing the narrative for me is not about adding to these diagnostic labels. It is not about saying Generation Z just need to toughen up and become a little bit more resilient (like people of my generation were, allegedly). It would not be about altering the current work capability assessments to reflect a changing digitally-powered employment environment.

Changing the narrative for me would be to recognise that all folk need hope in their lives. Hope that the world can become a more peaceful place. Hope that their life has meaning, ambitions are achievable and not blighted by limited access to education, poor housing, unsupportive communities and cost-of-living challenges. Hope that folks’ experience with everyday life struggles are recognised as being unique and needing a person-centred response, not a formulaic and process-driven one. We can do this if we (and policy makers) choose to change our narrative, where the story being told and shared, is about care, compassion, and empathy. Failure to do so fails the very generation, who will be there to provide our care and support, as we enter later life. And I for one, don’t want that.

Addressing mental health care? – I’m often lost for words

It is only in the last five years that I have discovered I had been living with a side order of dyslexia for most of my life. My brain often struggles to transpose the words I read into the words I try to say. This is particularly the case with new words, or words used in a new context. For example, during the Covid pandemic, I would dread having to report at our Board meetings or ask questions about our ‘nosocomial’ infection rates. Likewise, during the recent junior doctors’ industrial action, at first, I struggled to find the correct way of saying ‘derogation’. With both these examples, I now have no problem remembering how to pronounce these words correctly.

Other words I habitually mispronounce. The most noticeable and most used, is ‘exponential’ – which I often insert a ‘d’ into, so it become ‘expodential’. Every time I do, J will gently remind me there is no ‘d’, and every time my mouth and brain become disconnected and ‘exponential’ become mangled once more. It is a shame, as it is a great word and in a rapidly changing turbulent world, it captures the speed and pace of change exceptionally well.

I was thinking about this as I read two different, but related reports last week. The first was The Lancet Neurology paper, the Global Burden of Disease, Injuries and Risk Factors which was published last week. You can find it here. The paper noted that globally, a range of neurological conditions as diverse in range as migraine, stroke, dementia and Parkinson’s disease is now the leading cause of ill-health. Although the report draws upon 2021 data, it is the most comprehensive study of its kind to date.

The report makes for a challenging and frightening read. The number of folk living with, and/or dying from disorders of the nervous system, has risen dramatically over the past 30 years. Almost unbelievably, some 34% of the world’s population (3.4 billion people) were affected in 2021. The rate continues to rise exponentially. In the UK, one in six people have some form of neurological condition. Nearly three million of this group live with the after-effects of a stroke or traumatic brain injury. My mother is one of the 944,000 people living with dementia. By 2030 (just six years away) this number is expected to rise to one million.

Today, the fastest growing neurological condition is the nerve damage cause by diabetes, perhaps reflecting the exponential rise in Type 2 diabetes; a statistic also reflecting the rise in folk living with obesity. Whilst for many of these conditions there is no cure, this is a great example demonstrating that many of these conditions are preventable. The report noted that modifying 18 risk factors over a person’s lifetime could reduce the number of people having a stroke, reduce the risk of early onset dementia, and tension-related headaches. Currently, the latter complaint, tension headaches, affect two billion people worldwide.

The most common causes of tension headaches include stress, sleep problems and a high caffeine intake. It is always good to be able to learn something new along the way, and writing this blog I discovered the paradoxical problem of taking painkillers too often or for a long time can result in headaches, called rebound headaches. So, perhaps save those paracetamol tablets for when you really need them. Tension headaches usually last no more than 30 minutes, and most folk should be able to carry on with their everyday activities.

The second report I read last week, published by the Department for Work and Pensions (DWP), set out the figures for folk, who have been deemed incapable of carrying out everyday activities, and importantly, are also unable to work, because they are living with a mental health problem. The DWP data showed that two million people are receiving universal credit health benefits, an exponential rise of 400,000 in just one year. Some 69% of these folk have been judged unfit for any work. The health assessments undertaken revealed some interesting, but also challenging facts.

Nearly 70% of all claims were for people who had mental and behavioural disorders. This compared to 48% of claims that also involved back and joint problems, and a fifth where there was heart disease noted as well. This is data that illustrates the growing (exponentially) problems faced by so many experiencing mental health problems who can’t work, but it fails to show what the impact might be on individuals, their families, and the communities they live in. What helps put this into perspective for me is the knowledge that there are nearly two million people on waiting lists for mental health treatment and care in England.

If access to effective mental health care was more readily available, many of these folk might be able to return to productive employment, which would be good for them and our wider economy. In 2023/24 the UK government spent over £265 billion on paying pensions and benefits, nearly half of which was in benefits. During the same period, the spend on health care was £245 billion. If nothing more is done to help those people, who can’t return to work for whatever reason, these costs will riseexponentially year after year. However, if nothing more is done, the real costs will be those faced by the many individuals who continue to not have their mental health needs met in an appropriate and timely way.  

Advertising for a healthier life

When was the last time you saw a billboard that made you stop and smile? Or maybe think, that’s a clever bit of advertising? Have you ever bought something because of what you have seen on a billboard? I have. Well, it was a service rather than an object or item. I was prompted by a Specsavers advertisement to go and get my eyes tested, which I did. The test was free and the Specsavers billboard advertisement at least got me into their store. However, I thought the price of their glasses was exorbitant and left with just my prescription. I was able to get this filled by an online supplier for a fraction of the price.

It was the late author, historian and art collector, Dr Jeffery Lant*, who is credited with developing the idea that people must see or hear an advertising message at least seven times before they take action – this is the so called ‘Rule of 7’ marketing approach. Advertising on billboards is a great way of utilising this concept. It’s why we see so many on roads, the side of buildings and so on, in fact anywhere where there is likely to be large numbers of people passing every day. It is estimated that most of us spend up to three hours and 10 minutes each day being ‘out and about’. Many companies will spend significant sums of money with advertising firms to create advertisements that are eye-catching and clever.

However, this approach can sometimes go spectacularly wrong. One of the most complained about billboard adverts ever was the Sophie Dahl Opium advert. It was certainly eye-catching, but deemed offensive, sexually suggestive and degrading to women. It was eventually banned and was only allowed to feature in a limited number of magazines. Whether the controversy led to an increase in sale of the perfume I don’t know, but it did show the power such advertising can have in engaging public opinion.  Likewise, the now famous ‘Labour isn’t working’ poster used by the Conservative Party in the 1979 general election is said to have contributed to the election of Margaret Thatcher, the UK’s first female head of state.

Where billboards are located is also important. Last week Adfree sites (a group that campaigns against the expansion of advertising) published a piece of research that looked at the relationship between advertising, income, and deprivation in England and Wales. Interestingly, they found that over 80% of all billboard advertisements are to be found in areas where folk have little or low amounts of disposable income. The researchers argue that advertising found can often negatively impact on peoples’ lives, as they tend to focus heavily on unhealthy fast foods, and alcohol for example.

One of the report’s authors, Professor Emma Boyland, noted that such advertising risked worsening health inequalities, and more so in the case of children. Rising levels of obesity and diabetes in children for example, have been linked to unhealthy diets often consisting of ultra-processed foods and the over indulgence of takeaway meals. Last year, three of the most well-known fast-food chains in the UK were among the top five spenders of billboard advertising.

There are no easy answers to address this problem. Such advertising can be big revenue generators for local councils. Once billboards are granted planning permission, it can be difficult to get them removed. However, whilst advertising unhealthy foods and alcohol can lead to unhealthy consumption, these are just two factors contributing to individual and population health inequalities. Low income, smoking, poor housing and physical inactivity are also major contributing factors.

Have a look at the comprehensive King’s Fund report here for a much fuller explanation of the impact these and other factors can have on individuals and populations. Sadly, Blackpool, where I now live, features badly against most measures of health inequalities.

We also know that folk with a low income and or living in poverty will find it much harder to access healthcare than those in higher income communities. This is particularly true when trying to gain access to primary care, mental health services and dental care. There are many reasons that add to these difficulties. Taking unpaid time off work, the cost of travelling to appointments and the stigma that surrounds poverty. In addition, they often experience a worse response when they do manage to access such services.

I think there may well be an argument to spend some of the NHS funding on more health promoting advertisements. You might think this would be a costly diversion of money from frontline services, but set that cost against the rising costs associated with just treating obesity for example and it could be seen as money well spent.

 

 

*Speaking in 1997, at the age of 71, Jeffery Lant claimed he didn’t feel ready to retire – he said ‘my work can never be finished, because every time I put fingers to the keyboard, I like to believe that I’m changing the world just a little bit’ – sentiments I can identify with.

Avoiding a rhetorical nod to achieving parity of esteem

I’m tired and feeling my age this morning. I found last week was long and tiring, both physically and mentally. At times it felt like I was playing catch up, but without actually catching up. That said, there were some very interesting and good things along the way. Monday was our first Board development day at my new Trust. Such days can be exhausting in their own right. There is a considerable amount of planning that goes on before the day and the delivery of the sessions can be unpredictable and demand full attention and concentration; more so, perhaps, where I’m facilitating a particular session. We did have a couple of excellent facilitators on this occasion, however, and that helped share the load. Apart from one person, we had the entire Board in the room. No laptops, phones or other distractions, everyone was physically and emotionally ‘in the room’. This helped ensure there was a good buzz throughout the day.

I described the day as a success. The focus was on developing ourselves as a Board, exploring what notions of ‘consistency’ and ‘continuity’ might mean for us individually and as a group. This felt particularly important, as the Board membership would be changing over the next six months. One outcome from the day that will go a long way to ensuring smooth transitions was being able to find out a bit more about the person behind the job title. Sounds a rather strange thing to say, but how much do we actually know about the folk we work with. I’m sure many of us might think we know something about the other, and of course things, like being married, having a long commute, being vegetarian and so on might be well known. Whilst helpful, such knowledge doesn’t always tell you much about the person.

For example, I became a vegetarian some 50 plus years ago. At the time, I had strong beliefs about killing animals just to feed ourselves, when there were so many other ways to feed populations. These days I’m less strident about such views; indeed, J cooked a rump steak for her dinner last Friday. It was something she enjoyed and which, despite my beliefs, her joy made me happy too. A simple example perhaps, but it does illustrate the complexity of our self, and our self in relation to others.

Whilst the Board development day was successful, it was somewhat predictably, top and tailed by other meetings. So, an early start and late finish to the day. Long days continued throughout the week. I had three consecutive 16-hour days, one of which involved whizzing down to London for an all-day NHS England meeting. It was a meeting between the NHS England Board and Integrated Care Board (ICB) and Provider Trust Chairs. Despite being born in London and living there for much of my childhood and teenage years, I don’t like particularly like the place. I find it crowded, noisy, dirty, expensive and often unfriendly.

In contrast, the meeting was a great opportunity to both nurture existing relationships and to build new ones. It was a chance to share experiences and challenges, and of course to meet with the NHS Board members. And in the midst of some doom and gloom presentations, there was a threshold moment of change in tone and approach by the NHS England Board. Frequently, by which I mean always, the focus is on the acute sector. Most presentations are framed around waiting lists, urgent and emergency care, reductions to cancer diagnostic waits, reducing costs and increasing productivity.

This focus is unashamedly often defended on the basis that such concerns are what forms the subject of today’s existential political gaze. It’s a fine example of the Foucauldian assertion of the impact that State intervention can have on what shapes our everyday lives. It also, perhaps, says something about how much our current politicians actually understand about the reality of health and care services.

The threshold moment? Well, a colleague from a mental health Trust cut across a speaker in mid flow and said ‘Enough! Where, in all of this, is the parity of esteem with mental health?’. A somewhat pregnant pause followed, before the speaker resumed, this time acknowledging the skewed focus of her presentation. Thereafter all the speakers apologised, at the start of their presentations, that their focus was exclusively on the acute sector. Although it was great to witness, and be a part of, I hope the change in tone was something more than a rhetorical nod in the direction of mental and physical parity of esteem.

A lighter moment came as the ‘Prophet of Doom’, Julian Kelly, Chief Finance Officer for NHS England, declared that the Mental Health Investment Standard (MHIS) would continue to have ironclad protection. MHIS was developed to ensure an increase in the investment in mental health services across England recognising the historic underfunding of this sector. It was previously known as the ‘parity of esteem’.  He also noted that the one area of health care where he didn’t expect to see a reduction in the workforce was in mental health services. He got a hearty round of applause for these declarations. It was noted that, prior to this, Julian had never been given a round of applause for anything he had said or announced. Recognition that there was no health without mental health remained a consent theme throughout the day – I hope such recognition continues and is truly translated into actions too.

As for my tiredness. I need to take my own advice and try and have a rather more slowed down pace of life, perhaps to say ‘no’ more often to requests for my attention or help, and definitely, the next time I go to London, to book a hotel for the night before the meeting! However, I also know booking a hotel is the easy thing to do, changing other things impacting on my work-life-balance might be much harder to achieve.