The need to regulate the regulators with a little more compassion

 Reading Friday’s news regarding the Care Quality Commission (CQC) took me back almost 24 years, when I became a reviewer for the Commission for Health Improvement (CHI). I can vividly remember the selection process. It was an assessment centre held over two days. It was one of the toughest, (but most enjoyable) assessment centres I have taken part in. I recall there were a great number of applicants; most were drawn from the NHS.

I was appointed and during the three years that I worked with CHI, I undertook four organisational reviews, all in mental health organisations. These were usually carried out over a week, and the process was very intense. Every organisation was required to submit a range of written evidence on their services. More often than not, reviewers were given a telephone directory of information to read and make sense of. As well as observation, much of the work in each review was carried out by interviews.

The interviews were semi-structured; that is to say we had a range of set questions that everyone was asked, but there was always an opportunity to probe further should something emerge that was worth following up. The interviews and observational visits were aimed at gathering evidence around: patient involvement, clinical audit, education and training clinical effectiveness, use of information, risk management and staffing and management. There were two other overarching areas of enquiry: the patient experience and the organisation’s strategic capacity for developing and harnessing clinical governance.

Each interview was taped. At the end of each day the tapes were sent in a digital format to a company in New Zealand who transcribed and returned the transcripts the following morning. These were analysed and provided an opportunity to look for triangulating evidence. This was an important aspect of the review. Every concern or example of good practice required three different bits of evidence, before it was included in the eventual report.

Every day started early and ended late. However, we were well looked after. I like to think that, although there was a little bit of ‘learning while doing’, the outcomes of each review did make a difference. As a qualitative researcher, the use of narrative, stories and observation to counterbalance the hard statistical information was most welcome. CHI was disbanded in the Spring of 2004. After a couple of variations on a CHI theme, in 2009, the CQC became the regulator for health and social care services.

I found it interesting that in the early days of the CQC, many familiar names were to be found sitting on its Board. I try and steer clear of politics, but just Google ‘CQC’ (there are other search engines), look at the names of some of those involved in those early days and then revisit my blog posted the other week. I do wonder if the CQC troubles of today were seeded all those years ago. Just a thought. I have only ever been a recipient of CQC reviews. The outcomes have not always been good. Indeed, this year the CQC have undertaken many reviews into my current Trust, most of which have highlighted there is significant work to do to improve our services. For many of my colleagues, who do work hard at trying to improve our services, such an outcome can be incredibly demotivating and upsetting, particularly when folk have lost their trust in the whole review process. On several occasions, the CQC reports simply do not reflect the organisation I see and know.

Like many others, I have raised concerns about the current CQC review process. My concerns mirror many of those noted in Dr Penny Dash’s interim report published last Friday. The current (in a long line of…) Secretary of State for Health and Social Care described the CQC as not being ‘fit for purpose’. I would agree with his assessment. However, my thoughts are with all those folk that work for the CQC and/or undertake reviews.

Being part of a regulatory body is always going to be hard. I know that from my CHI experiences. The very public condemnation and excoriation of the CQC does not fill me with joy or delight. There are people involved here that are just like you and me. Many of them will be devastated  by this description of their organisation and work. So, if you know someone who works for the CQC or might be one of their reviewers, please show some compassion, reach out and be there for them at this challenging time. It’s time to care, not simply judge.

If you can change a childhood, you can change a life

Last week was certainly a strange one. We had fans of a presidential hopeful sporting ear bandages, a world wide web meltdown, and we all melted as the temperature in the UK rose above 30c for the first time this year. There were full-on riots in Leeds, a darts-loving teenage romance break up, and of course, a King’s speech at the opening of Parliament. The speech set out amongst other things, a renewed focus on mental health services and services for children and young people. A focus both most welcome and long overdue. 

When I first moved to Manchester, way back in 1984, it was to commission what was then, the only forensic mental health service for adolescents. The service provided medium secure in-patient care and community services to young people. It was a national service, and served young people who might otherwise, and inappropriately, enter the criminal justice system. It was a pioneering service, way ahead of its time. For me, it was also a time of great change, as I moved from rural Wales to big city Manchester.

In those early days I was privileged to lead a small group of other nurses, drawn from different parts of the UK, and all bringing different, but related, experiences. One of the Charge Nurses was a chap called Mike. He was a Barnardo’s child. Mike was one of the gentlest and most generous men I have ever known. I knew little about Barnardo’s until I met Mike. Barnardo’s was set up by a doctor called Thomas Barnardo way back in 1866.  Barnardo eventually gave up his medical practice to concentrate on helping children and young people who lived in poverty. At the time, poverty and the associated ill health was so widespread that one in five children died before their fifth birthday.

It was in 1870 that Barnardo opened his first home for boys. Despite the limitation of the building, he never turned away any child who needed help. Three years later, a now married Barnardo, opened up a home for girls. From these early beginnings, its work grew year on year. By the time he died in 1905, the Barnardo charity had 96 homes caring for more than 8,500 children and young people. In addition, the charity also supported 4,000 children who had been placed in foster homes. As the world moved on, so did the Barnardo model of care.

The rise of Local Authority residential provision for children and young people meant that by 1989, the charity has closed the last of its homes. These days Barnardo’s runs over 400 different types of services, ranging from day centres, day and residential schools and play schemes. They work with young carers, and provide support for homeless young people. Each year they work with over 100,000 children and young people. In terms of charitable expenditure, Barnardo’s remains the largest children’s charity in the UK. But they are not the only ones working with children and young people in the UK today.

Action for Children, another large children’s charity notes that there are 4.3 million children living in poverty in the UK. Sadly, this number is based upon 2022/23 data. That is 30% of all children living in the UK today. That cannot be right. Alarmingly, the number has possibly increased since this data was collected. In anticipation of a change in government, Action for Children, Barnardo’s, The Children’s Society, The National Children’s Bureau and the NSPCC along with more than 130 other organisations came together recently to plan how to make sure the next government prioritises children and young people. You can look at their campaign, ‘Children at the Table’ here.

Clearly the new government has heard their cry. I hope the King’s speech proposals turn into action, and do so soon. Amongst all the other things occurring last week, I was able to visit one of our Children and Adolescent Mental Health Services (CAMHS) at Bolton. I was impressed with what I saw and the folk I met. Originally this service was called the Lady Tonge Clinic. I don’t know when it lost that name.  Mike, my former friend, and colleague moved from the Adolescent Mental Health Forensic Service to work at the Lady Tonge Clinic. He is long gone now. However, if he had been with me last week, he would have been proud at what the service was doing. Truly they are helping to change childhoods and changing lives.  

Owls and Larks; there’s no time for sleeping, we have a job to do!

This past week, I have been really feeling my age. My long weekend trip to Vancouver to see The Rolling Stones, whilst very enjoyable, left me with the worst jet lag I have experienced in many a year. The 4,522-mile return journey home saw me flying East to West, which added to the problems of my body clock adjusting to the time differences. I’ve been tired and exhausted and found it difficult at times to concentrate. As I write this, I’m beginning to feel more like my normal self and when all is said and done, the concert was simply brilliant and well worth the effort. Thankfully, my body clock appears to have reset itself.

I have been an early bird for many a year. I don’t have an alarm clock and it doesn’t matter what time I go to bed, I always wake up ready to start the day before 4.30am. I do so every day. I was amused to read yet another story, last week, that looked at whether night owls or early birds have ‘superior cognitive function’. There is no definitive evidence one way or the other. The research looked at peoples’ reasoning, reaction time and memory function, and they found that night owls did better across all these areas than early birds. However, it was folk’s sleep patterns that really made a difference. The quality and duration of someone’s sleep are the factors that affect our brain performance. Research suggests that we need between seven to nine hours of sleep each night for our brains to remain healthy and functioning effectively.

There are exceptions to the rule. Famously, Margaret Thatcher, Winston Churchill and Barack Obama thrived on very little sleep. I have thrived all my adult life on five to six hours sleep a night. On the other hand, J does just as well when she enjoys seven to eight hours sleep. We are both active, do jobs that require us to use our brains more than our hands and we both write, play music and enjoy trying to beat each other at University Challenge. Clearly, the amount of sleep we require is a very individual thing.

Now I don’t know if our new Prime Minister is a night owl or an early bird. He will have, like me, I’m sure, had to deal with some jet lag given his transatlantic travels last week. What I do admire is his steadfast decision to try and avoid any work-related activity after 6pm on Fridays. I understand this is partly to do with his family’s faith, partly to do with being present for his family and partly to ensure a healthy work-life balance. I’m not being political when I say that for someone in such a high public office, he is setting a great example for the rest of us to follow.

Amanda Pritchard, the current NHS England Chief Executive, reminded us all last week that in the 76-year history of the NHS there have been 18 Prime Ministers, 34 Secretaries of State for Health and yet only nine changes of government since 1948. However, every change of government has at some stage, tried to ‘reform’ and in so doing, improve the NHS. Those of us who have been around the NHS for many years have become adept at navigating the various changes that have been introduced.

I vividly remember the elections resulting in the change of government in 1997. I had just completed the first data collection of my PhD. My participants were GPs and other primary care colleagues who were working in what were known at the time as GP Fundholding Practices. These operated in a so called internal quasi-market made up of purchasers and providers of health care services. Frank (Father Christmas) Dobson, one of the jolliest Secretaries of State for Health we have ever had, declared an end to the internal market. Considering the whole set up formed the basis of my PhD, I was pretty devasted. But I carried on. Whilst the internal market was disbanded, and GP Fundholders abolished, the subsequent establishment of Primary Care Groups (PCG) happened over the following two years. By this time, I had been able to modify my study and was able to complete my doctorate in 2000.

In 2001, PCGs were replaced by a fewer number of Primary Care Trusts, later to become Clinical Commissioning Groups in 2013. These too disappeared in 2022, being replaced by Integrated Care Systems that bring together health and social care services. Interestingly, there were two main protagonists who started this change process back in 1999. These were Frank Dobson’s successor, Alan Milburn, and the political strategist and advisor, Paul Corrigan. I don’t think I have knowingly met Paul Corrigan but I did once meet Alan Milburn in a first-class train waiting room, but that was over 20 years ago. I say interestingly, as Wes Streeting, the new Secretary of State for Health and Care has brought both of these folk in as advisors to help him tackle the issues facing the NHS. I never like to use the R word when it comes to the NHS, but I’m sure there will be changes to come yet again. They did it once and I’m sure they will do it again.

Indeed, some of these have already been signalled: moving care out of hospitals and into primary and community care; better use of technology and data; and boosting prevention and reducing health inequalities. Thankfully the discussions have put children’s health care, and mental health care front and centre in these plans. Like my jet lag recovery period, only time will tell how quickly the NHS can move forward in tackling the challenges and once again better meet the needs of our communities and the folk who live in them.

Music, travel, and connections: is this the last time?

Back in 1973, the brilliant game called Connect 4, was developed by the toy inventor Howard Wexler. It was a wonderful creation. Some of my grandchildren have spent hours trying to beat me. It is the kind of game that leads to almost compulsive playing. The game’s concept is relatively simple. Both players take turns to drop a blue or a yellow chip into a grid attempting to get four of the same colours in a line. Your opponent tries to stop you making this connection. The game is great fun, but you can lose hours of life playing it. I have thought about some different connections over these past few days.

Some of these connections have been flights. Last Wednesday, I flew from Manchester to Reykjavik and then on to Vancouver. As I write this blog it is 18.30, it is Saturday evening, and I’m sitting in Calgary airport waiting to catch a plane to Paris and then on to Manchester. Manchester is seven hours ahead of Calgary. So, I’m having to post this week’s blog now, as I won’t be back into the UK until Sunday afternoon. That’s if all the connections work. My memories of Charles de Gaulle airport are not happy ones!

In between these dates, I have been reconnecting with the greatest rock and roll band in the world, The Rolling Stones. I have seen them play live many times; the last being a wonderful concert at Anfield in June 2022. I thought that might be the last time (maybe the last time I don’t know – sorry). Quite by accident I saw they were touring again in the US, but I could not find a date that worked, hence flying out to Vancouver to see them, and maybe this will actually be the last time. It was an absolutely fantastic concert and well worth the effort to get here and see them. They connected with the 60,000 folk in the wonderful BS Stadium - there wasn’t a song where the audience weren’t singing along. Most of us men folk were playing air guitar as well. It was Hackney Diamonds all the way and a truly magical night.

The last time (Okay, that’s enough of The Rolling Stones’ references) I was in Vancouver, was in 2006. It was for the first International Nurse Education Today/ Nurse Education in Practice (NET/NEP) Conference. I had just been appointed as a Professor in Mental Health Care at the University of Salford. My paper was entitled ‘Fragmentation and Integration in Primary Health and Social Care’ and was drawn from a project aimed at understanding what factors might shape UK primary care services of the future. The research project was the first one for me where the grant awarded was £750K+. In that same year I also went to Alice Springs, Australia, to present at a conference there. A memorable trip for many reasons, not least of which was me inadvertently jumping into the hotel swimming pool with a USB stick containing a grant application I had worked on for days in the pocket of my trunks. The USB stick didn’t survive and I was unsuccessful with the application.

The other connection with Vancouver was meeting up with a young man called Jozeph Betleham at that conference. He lived in Hungary, and I had met him about five years previously on an EU ERASMUS exchange trip. At the time I was working at Manchester Metropolitan University, and Jozeph was one of my PhD students. We alternated supervision sessions. I would go to Hungary, and Jozeph would visit Manchester. So, it was wonderful to meet up with him again in Vancouver all those years later. While J and I were recently travelling across Eastern Europe on our Grand Train Journey, hitting Budapest in Hungary brought back some of those great memories.  

The two weeks we were away from the UK clashed with both the Lytham Festival, something we have supported for a few years, and of course Glastonbury. I have never been to Glastonbury, but have enjoyed the festival from afar through catch up TV. And of course, the Rolling Stones played at Glastonbury in 2013. Like last night, at Glastonbury they played 20 songs during their two-hour performance. Such energy!!! This year I was pleased to watch Seasick Steve perform, and I absolutely need one of those cigar box guitars to add to my guitar collection.

The Glastonbury highlight for us this year though was the Coldplay performance. We saw them at the Etihad Stadium in June last year. It was a fantastic performance very much like this year’s Glastonbury show. Whilst we like their music, we are also on the same page when it comes to their commitment to working towards a more sustainable future. Their last tour cumulated in them reducing the carbon impact of their concerts by nearly 60% compared to where they were back in 2017. Amazingly, since that time the group have funded the planting of seven million trees. Our three or four trees planted each year pales into insignificance for sure. They do have to use airplanes and big articulated trucks to move their equipment around between shows. They have a lot of equipment. However, the band’s lead singer Chris Martin always tries to use public transport when he can. At the group’s recent concert in Cardiff, he arrived on the train. Which is another couple of connections for me and I guess a cue to finish this blog and get ready to fly to Paris. Normal service will be resumed next weekend.