Working on health creation and virtuous circles

Since I attained working age, I have only ever been unemployed once. Indeed, there were periods in my life where I held down two or even three jobs at the same time. However, for a couple of months, I found myself in-between jobs with no notion of what I wanted to do next. During this time, purely to get my National Insurance stamp paid, I registered as being unemployed. This was in the days where you went along to the ‘Job Centre’ answered some questions over your eligibility for various benefits, and importantly, looked at the row after row of little cards each advertising jobs; none of which appealed.

It was a strange time in my life. I needed something to do, but working in a warehouse, a shop or as a salesman wasn’t ever going to cut it. I had an MBA for goodness’ sake. I had just left the NHS and although a qualified nurse, I also didn’t want to go back into nursing practice. I wanted to go into education. Fortunately, I was able to do so and enjoyed a later-life second career in higher education. I went from being a Lecturer to Dean of Faculty. I have long retired now and what I do these days, I do because I want to, not because I need to. In that regard I know I’m fortunate. Many others aren’t.

The IPPR thinktank estimates that Britian has lost 900,000 people from the labour workforce since the pandemic. Not that I’m a great fan of HMRC, but this loss results in £5bn less tax being gathered this year. Less taxes means there is less money to support the public services that we will all use at some stage in our lives: education, defence, health and so on. Interestingly, they also suggest that if were able to improve the nation’s health, we could save the Government £18bn a year in benefit cost.

So perhaps it was no great surprise that, last week, our new Secretary of State for Health and Social Care, Wes Streeting, announced at the Labour Party Conference, that he was making it a priority to cut waiting lists in those areas, which have the highest number of unemployed people. His focus is on those folk not working as a consequence of ill health. We know that three million people of the estimated nine million people who are economically inactive, are neither employed nor looking for work due to either acute or long-term health problems. It is also worth noting that there are 6.4 million people in England, who are currently on NHS waiting lists for treatment.

I’m not economically inactive. I still pay frustratingly large chunks of my income in taxes each year. That said I probably benefit from being in that ‘baby boomer’ virtuous circle of living through a time of much greater economic prosperity than many folk might experience now. I came of age before the ending of the Vietnam War and the Watergate scandal. It was a time of great technological change too. Things we take for granted now, fridges, TVs, washing machines, cars and even telephones (those attached to a cord at least) all became more readily affordable, and of course more desirable.

However, I think one of the greatest benefits of being a baby boomer were the changes in health promotion, ill health prevention and greater access to health care services when these were needed. Vaccines against polio, measles, whooping cough were all introduced, greatly reducing the occurrence of these diseases in children and young people. As a young person, I remember being excited (as were my class mates) to see if my Mantoux TB test showed positive. I was very naive then. Thankfully I did get to have my BCG vaccination. Compared to the many children and young people I met during the school Covid vaccination programme, most of whom were very knowledgeable as to why it was a good thing to have the vaccination, I was much less clued up at their age!

If I’m somewhat cocooned in my virtuous circle, I think last week Wes was reminding us of those folk who might find themselves in a more vicious circle. Research shows there is a strong link between an individual’s employment status and their health. Unemployment has consistently been shown to be the biggest factor in having a negative impact on a person’s mental health and wellbeing. Anxiety and depression, for example, can very easily reduce someone’s chances of both seeking and securing employment.

People who are unemployed are five times more likely to live with poor health than those in employment. Currently, there are nearly a million job vacancies in England. Helping people caught up in this vicious circle to be able to return to the job market and take up some of these opportunities, makes as much sense to society and it does to the individual. Sadly, I don’t have many ideas as to how we might do this, and unfortunately, I’m not sure Wes has the answers either. I would, however, urge readers to have look at the latest IPPR report on health and prosperity, see here. I like their ambition to change our approach from having a reactive NHS health system to a more proactive health creation approach.  

Foxes, chickens and improving our wellbeing

Last week was highly enjoyable. It was full on and very busy, but totally rewarding too. Every day (except Friday) started at 4.20am. Whilst these days are shorter, and the sun still has nearly three hours before it rises, it is a great time of day. Well at least for me, not so much for J. More of which later. At this time of day, it is surprising what you can see, if you are observant. Monday started off very foggy. It was a thick fog that made me cough, as I walked Dylan for his first walk of the day. However, we stumbled across two young fox cubs playing in the park. I don’t know who was more surprised, them, Dylan or me. It was a privilege to share the space with them though, albeit for just a few moments.

I wouldn’t have always said that. Indeed, over the years, I have lost many a chicken to foxes. When we moved into our current house, our chickens were killed within days. Unbeknown to us and our next-door neighbours, a pair of foxes had made their den in a disused greenhouse at the bottom of their garden. Following the loss of our hens, I made a fox-proof hen enclosure, we bought some more hens, and the foxes moved on, as the neighbour’s greenhouse was brought back into action.

When I lived in Wales, all the local farmers would go for a Boxing Day hunt for foxes. Not on horseback, nor wearing red coats, but walking the fields with loaded shotguns, trying to ferret out a fox. It was far more dangerous to us than it would ever have been for the fox. Some 40 years on and out on our walk yesterday, we came across a sign that prohibited armed trespassers on the land we were passing through. The sign also informed us that it was prohibited to go shooting on Christmas Day in Lancashire! These days, J and I love a good walk on Christmas Day, but as I gave up my shotgun when we got married and wouldn’t go hunting these days anyway, it is just a walk allowing us to get close to nature.  

Back to those early starts. It is the perfect time of day for me.  The author, eye surgeon, and neuroscience researcher, Mithu Storni, published her book ‘Hyperefficient: optimize your brain to transform the way you work’ last week. In it she notes that people are not machines, therefore working in linear ways (9-5, Monday to Friday) is not always going to allow our brains to function effectively. She advocates several changes we could all make to ensure we function in more creative ways. The first of which is that early mornings and late evenings are prime creative times. However, it is not just getting up early that counts, it is what you do with the time that is important.

No TV, steer clear of social media, avoid coffee and find something that just allows your mind to slowly embrace the world around you. For me that is walking Dylan first thing. As  I walk, I let my mind reframe how I might get through my day, whatever is in my calendar. By the time I get to my desk at 6.30am, I’m more often than not seeing the world through a more positive lens. Storni has another tip that I already use. Try working in bursts of 60 and no more than 90 minutes. Importantly, during that time, tackle the most difficult and challenging tasks first.

The pace of our working lives has changed over the last two decades. We are expected to do more with less, to be super effective and efficient. Often this results in a sense of being overwhelmed, and consequently totally impotent and unable to move things forward. It is an all too familiar place that many of us often find ourselves in. However resilient we may feel we are, the sheer scale of the ‘ask’ can, at times, result in us simply not being able to do anything. This state of being can bring with it a vicious circle of despair, a lack of self-confidence and, of course, make us unable to do what others are expecting us to do. I’m sure we have all been there at times. I know I have.

The longer-term consequences of such stress on our mental health and wellbeing are well known. Anxiety and depression continue to be major causes of people being off work in the UK for health reasons. There are now more than 1 million people in England waiting for NHS-provided mental health care. Last week, this year’s global Ipsos Health Service Report was published. It makes for an interesting read. According to the their report, in the UK, mental health is now the number one health problem people worry most about, overtaking worries about cancer and obesity. In a post-pandemic world, stress and its impact upon people’s mental health and wellbeing is viewed as the area of life that 54% of the population are most concerned about.  

Getting up early and making sure we have a slowed down start to the day won’t stave off everybody’s stress or anxiety. We can, however, all find ways of engaging in activities that might help us have a better, more balanced and fulfilling life; see here for tried and tested approaches. Life is precious, let’s all try and make the most of the time we all have. If in the moment these don’t help, just remember it is okay to not feel okay all of the time.

Finding calm and quiet in an ever increasingly noisy world

Here is a pub quiz question: - where is the loudest city in the world? – according to the United Nations, the answer is Dhaka in Bangladesh. Apparently, the noise in the city is a major public health concern. Many people living there experience hearing and sleep problems, and have a higher risk of hypertension and mental health problems, due to the constant noise. The top ten noisiest cities in the world in descending order are Dhaka, Mumbai, Ho Chi Minh City, Moradabad, Cairo, Delhi, New York, Beijing, Buenos Aires and Los Angeles. I have been to five of these cities and can testify to the negative impact the noise can have on one’s mental health and wellbeing.

New York was in the news last week for other reasons. Incredibly it has been 23 years since two hijacked planes were deliberately flown into the twin towers of the World Trade Centre in New York. 2,606 people died on the day itself or later from their injuries. A further 125 people were killed as a third plane was crashed into the Pentagon. There were four planes involved in these attacks and all 246 passengers and crew on the planes were killed too. 19 of the hijackers who committed murder-suicide also died. The September 11th attacks were the deadliest terrorist attacks in human history.

I have been to New York many times. Here is a picture from one of my earlier visits. It was taken 38 years ago. I have changed since then and of course, since the attack, the world has changed too. Talking to colleagues last Wednesday, without exception, we could all recall precisely where we were when the attacks happened.

More recently J and I visited New York and one of the most poignant moments of our trip was spending time at the National September 11th Memorial and Museum. The memorial’s design is called ‘Reflecting Absence’ and was designed by Michael Arad and Peter Walker. For those readers who have not been there, the memorial is made up of two recessed pools (the footprints of the twin towers), set in a field of trees. It was opened six days after my birthday in 2014.

It is a most humbling place visit. All the names of the victims are inscribed on the walls around each pool. A white rose is placed on top of each victim’s name on their birthdays. Amid a still bustling and noisy New York, the quietness and stillness of the memorial is almost unbelievable. I have visited many famous places, but visiting the 9/11 memorial remains one of the most moving and profound experiences of my life. 

Manchester doesn’t feature on the top 10 list of noisy cities. However, it is still a busy, bustling, and noisy place to live and/or work in. I was in the city centre last week to participate in an induction and training day for some of our Council of Governors. The day was spent in the Manchester Friends Meeting House, and it was very successful and highly enjoyable day too. There has been a Quaker community in Manchester since 1795. The Friends Meeting House is a Grade II listed building, built in 1828. One of the most remarkable things about the place is that, as soon as you walk through the building’s front doors you enter a world of quiet, stillness and calm.

I try and avoid religion and politics in these blogs, but the Quakers are an interesting group of people. They are just ordinary folk like you and me. Indeed, when I worked in Wales as a Charge Nurse in a community hospital, our visiting GP was a practising Quaker, and a wonderful man too. As a community, Quakers have simple, but clear values. These include promoting peace, equality, simplicity, and truth. They try and live their lives according to these values. Throughout history, Quakers have been involved in many humanitarian issues, including the abolition of slavery.

These days Quakers continue to work for peace, protecting the climate and social justice. The Manchester Friends Meeting House is an oasis of calm and stillness in a very bustling city. It epitomises the Quaker endeavour to create spaces for people of all faiths, backgrounds and social position to come and just be in a place of quiet, stillness, and contemplation. In a sometimes very noisy, busy, and impersonal world, this is a much-needed space. Of course, you don’t have to go to a building like the Friends Meeting House to find such a space. I practice mindfulness. Whilst I will sometimes go and sit on a favourite bench or walk to a particular favourite spot, I can also sit in my car or my office, lay in my bed and in all these spaces connect with my own thoughts and feelings, and to the place I find myself in at the time.

In a world that often sees us rushing about, place to place, meeting to meeting, it can be easy to become disconnected from the world around us. When this happens, it can also be easy to become disconnected from our thoughts and emotions and the behaviours these might shape. Mindfulness can help us become more aware of our thoughts and feelings as they happen in the moment, and moment to moment. In turn, pausing in this way will help us improve our mental health and wellbeing. You don’t have to be a Quaker to sit silently and pay attention to your thoughts. We can all create our little oasis of calm and stillness, and in an ever increasingly turbulent, noisy, and busy world, that must be a good thing.   

Time machines and revisiting community mental health services

Last Monday I climbed into a time machine and went back to the 1980s. Actually, it was a VW Passat and it was still Monday morning in 2024. But it did feel like I was going back in time. I spent the day visiting our Community Mental Health Teams (CMHT) across Salford. My first stop was Prescott House. This was the first ever purpose-built CMHT facility in Salford, and one of the first in north west England. At the time (1987) I was a Nursing Officer, responsible for acute admission and community services in Salford. It was time where mental health services were closing beds at a huge rate, and where there was greater investment in the provision of community mental health services.

I remember Prescott House being built and the excitement there was at having Community Psychiatric Nurses (CPN) sitting alongside social workers, doctors, occupational therapists, and psychologists. It was absolutely a brave new world. It wasn’t without its problems, mind. Although the multiprofessional team worked together, they were employed by different organisations, all of whom had different employment practices. Indeed, the very first paper I wrote and had published in 1989 was titled Multi-disciplinary teams and line management: practical problems and areas of conflict in clinical psychiatry. The paper was co-authored by a social worker, chief executive, and a psychiatrist. It would be 10 years before I wrote and published my second paper – more of which later.

The psychiatrist was a chap called Som Soni. He became an early mentor for me and certainly whetted my appetite for an academic career. Once a month, I would join him in the hospital library and he would show me how to read a research paper. I learned a great deal from him, and not just about psychiatry. He was a generous man and a people person. In the summer time, he would invite colleagues he worked with to his house in Hale Barns (a very desirable area of Greater Manchester/Cheshire) for a summer party, which included a dip in his swimming pool. He also worked at Cromwell House, the next CMHT facility I visited on Monday.

However, just before we leave Prescott House, I saw a very familiar name on one of the office doors – Gareth Holland. He is now a Senior Practitioner. In 2013 Gareth and I wrote a chapter about decision-making in mental health nursing. It went into an edited book called Understanding Decision Making Skills in Nursing Practice. The book is now in its second edition, revised to show the lessons learnt during the Covid pandemic. Gareth was on holiday so I didn’t get to meet him, but his colleagues said he was very proud of that chapter – and so he should be!

Cromwell House was the second CMHT facility to be built and this was/is a much grander building. More space and a larger team. Unlike Prescott House, which to be honest looked a little tired, Cromwell House still looked a reasonable building and place to work. Of course, much of the CMHT work is done now in people’s homes, but there were good drop-in facilities and therapeutic spaces. Interestingly for me, in my discussions with colleagues, I heard a proposition to develop a mobile service. Again, drawing on the experiences and lessons learnt throughout the Covid pandemic, the idea would be to provide a mobile clinic, which could provide services and care to folk directly within their neighbourhoods. It is a great idea for sure.

My penultimate visit was to Ramsgate House. This was the last to be built and from an architectural point of view, it is the most stunning. It is situated a stone’s throw from HMP Manchester (what used to be called Strangeways prison). It has a working and therapeutic environment that felt safe and welcoming; which, if you know the area, is saying something. I had lunch with one of the psychiatrists and our discussion was far-reaching. He clearly enjoyed his clinical work - sadly did not want to get involved in anything that even vaguely looked like management - but above all, was passionate about transforming clinical services.

It wasn’t so much that the current CMHT weren’t providing a great service, he (and I) felt in the main that they were. But more could be done up stream, to help people stay healthy and reduce the many determinants that impact upon people’s mental health and wellbeing. His ideas as to how we might do this were being fed into our ‘transforming community services’ programme.

My last visit of the day was to our Living Well service. Here, I was able to see some of these ideas being put into practice. The Salford Living Well service was one of the first three such centres in England. There are many more these days. I heard how colleagues were having a real impact and you can see here what this might mean for individuals, communities and other mental health services. It is absolutely the way forward. We will still need in-patient and CMHT services, but the Living Well approach will go a long way to reducing our inappropriate use of such services.

And that second paper? Well, I wrote a critical analysis of what I believed to be the changes, challenges and opportunities arising out of the publication of the New NHS White Paper in 1997. This was the than Labour Government’s grand new plan for the NHS, and introduced NHS Trusts, Primary Care Groups and much of what we see in our NHS today. Darzi 2 is a review that has been commissioned by the current Labour Government into NHS performance and will provide the basis for a 10-year plan which aims to get the NHS back on track and fit for the future. It is due to report by the end of this month. However, I don’t think this time I will be tempted to write another analytical paper on whatever the report might say. Actions, as is often the case, speak more loudly than words.

Use your loaf when it comes to quitting smoking – you know it makes sense.

Well, my cold and cough didn’t start to get better until last Friday, and even as I write this blog, I’m not feeling 100%. Thanks to all of you, who have sent me the warmest wishes and just to reassure folk, I have not been suffering with this new nasty Covid variant. It’s just a summer cold, albeit verging on man flu. I’m glad to have been told, however, that my Covid and flu jab will be available on 3^rd October. Despite the current GP ‘work to rule’ industrial action, my practice seems keen to try and keep me safe.

Now, as J will tell you, having a slightly incapacitated man about the house is not without its problems. One of which is that I’ve had plenty of time to read. And read and read and read. Which has resulted in my reading material getting into some fascinating weeds somewhat this past week. As I’ve done so I have been amazed, stunned, and saddened by what I didn’t know.

Here are some examples: I didn’t know it was an EU ruling that we all must now have tethered caps on our soft drink bottles. Brexit UK still must abide by these rules although we now have no MEPs to challenge any of them. Remember that, the next time you catch your lip on one of these annoying attached lids. TBH, I detach the cap, as soon as I open the drink.

I also didn’t know that anyone would be daft enough to pay £4.50 for a loaf of bread. Apparently, residents of Bathford (near Bath) are. They are rapturous about their locally-baked bread. But they are also up in arms because local AirBnB owners are buying up all the loaves, as soon as they are baked, to serve to their guests, before locals can get themselves out of bed and to the shops. Even though 3.12 million people used foodbanks during 2023/24, and there are over 14 million people living in poverty in the UK (4.2 million are children), one of the Bathford locals declared that getting good bread was practically a human right. A first world problem, if ever I saw one.

Something else I didn’t know until yesterday was that our current Deputy Prime Minister is into raves. She did seem to be enjoying herself, which after all, is the point of being away on holiday. And, more importantly perhaps, she wasn’t dancing, drinking, and having a good time in someone’s garden during a pandemic lockdown. I also hadn’t clocked that she was a smoker. How that will play out for her in the future as the Prime Minister introduces the no smoking ban in pub gardens and outside night clubs. It’s a policy long overdue. However, I know from the many occasions I have asked patients and visitors to stop smoking on hospital grounds and been told to go away and have sexual intercourse (or words to that effect), it can, and will be difficult to enforce.

The World Health Organisation estimated that across Europe, 2.7 million people a year die because of consumption or exposure to four products: alcohol, tobacco, ultra-processed food and fossil fuels. In Britain, this means there will be 184,000 people diagnosed with cancer, as a direct result of obesity, smoking, alcohol misuse or a history of sunburn. Total societal costs for obesity in the UK are estimated to be £95bn a year, alcohol harm £27bn and smoking £46bn a year. Providing health and social care to people living with such health-related conditions costs the NHS £4bn year. All told, it’s a lot of money that could better spent in other life-enhancing ways, such as reducing poverty.

To be honest, I’m not concerned with the proposed outside space ban on smoking. It makes perfect sense. However, there is one group of people that the ban could affect which does concern me. Whilst the overall number of people smoking continues to reduce, people living with a serious mental health problem and who also happen to smoke has remained at a relatively constant high level. Like all NHS services, smoking cigarettes on our premises is forbidden for all. This includes our mental health service users who may spend some time on an admission ward. Many of these folk smoke cigarettes. Helping them to stop can be a real challenge.

All our inpatient services have outside areas which people use for different activities. We do our bit to encourage service users to stop smoking, but where this isn’t right for the person at that point in time, we allow vapes to be used. Indeed, last year the NHS and Local Authorities spent between £50 and £70 million across England to help people stop smoking using free vapes. There is now a good body of evidence that suggests vaping is better for an individual’s health than smoking. Vaping is emerging as the best way to help smokers of all ages to eventually quit their habit.

However, there are some folk who would like to see no cigarettes and no vapes being available to anyone. The recently introduced Tobacco and Vapes Bill (which increases the age at which someone can buy tobacco, so anyone born after 2009 will never be able to buy cigarettes) will clearly help in the long term. The jury is out on the long-term effects of vaping, and clearly the exponential increase in the number of children and young people who have started to vape is of concern. We won’t know for a couple of generations what impact vaping might have on a young person’s physical health in later life.

Closer to home, the Care Quality Commission, during their reviews of our services, almost routinely criticise us for allowing our service users to vape, something service users can only do outside. I routinely praise my colleagues for encouraging our service users who smoke to switch to vapes. Giving up smoking can be as hard or even harder than giving up heroin. On the other hand, would I worry about missing out on a £4.50 loaf of bread, I don’t think so. That would be very easy to give up!