Shifting left: challenges we can all relish!

It is thought that the phrase ‘a legend in your lifetime’ was first used to describe the life and work of Florence Nightingale. She was, of course, a nurse first and a medical reformer second. It was said that Florence Nightingale ‘combined the intense vitality of a dominating woman of world with the mysterious and romantic quality of a myth’ - a description that reflects her passion, knowledge, courage and determination to make a difference.

On a slightly lighter note, Peter Hawkins, in his 1969 play ‘The Dynamic Death-Defying Leap of Timothy Satupon the Great’ describes his hero as a ‘legend in his own lunchtime’. In the play, Timothy, although being a reasonable and a likeable lad, day dreams of future greatness, but in reality, he never quite makes it or indeed, ever makes a difference.

Now I’m proud to be a nurse, albeit I stepped off the register a while ago now and no longer practice. Although I never attained the greatness of Florence, equally, I don’t think I’m a Timothy either. There is, perhaps, a legendary place somewhere between the two. My musings over Florence and Timothy arises from where we find ourselves as a national health service since Friday. Once again, resident doctors have chosen to take industrial action. It is, of course their right to do so. Their reasons for doing so this time, however, appear somewhat contestable. It was something I touched upon in a previous blog, posted just 14 days ago. 

However, it is not my intention to argue whether the industrial action taken by the resident doctors is justified or not. Currently, most doctors, including Resident doctors in the NHS work in hospitals. Inevitably despite what both sides of the dispute might say, harm will occur to individuals, families and the wider NHS. When that happens, it will be an outcome that is sad. The recent publication Fit for the Future, the Government’s 10-year health plan, provides a unique opportunity to change the UK’s approach to how we approach health care. And in my view (and the view of plenty of other folk I think), an absolute paradigm shift for good.

Whilst Florence was busy establishing a fully trained and regulated nurse profession, she was also reforming the function and practice of hospital-based care; moving it from a place of last resort and despair to somewhere people trusted and where they would receive safe and consistent care. Ironically, perhaps, one of the major so-called ‘left shifts’ outlined in the 10-year health plan is to move care from the hospital to the community, and in so doing make hospitals a place of last resort, but for different reasons!

A second ‘left shift’ is from illness to prevention; moving help upstream and earlier to prevent folk needing to access more expensive secondary care services. This will have an enormous impact upon the ever-increasing demands asked of health and care services. Florence recognised many of the underlying detriments that give rise to health inequalities, and poor life opportunities. Her ideas around the importance of good housing, sanitation and nutrition are ideas which continue to be built upon by others and which have helped societies around the world reduce the number of life-shortening diseases and avoidable health issues – but there is still a long way to go.

The third ‘left shift’ in the Fit for the Future plan -  ‘analogue to digital’ - would, I think, have enthralled and inspired Florence. She was a great statistician and knew how to use data to ensure informed decision-making and promote evidence-based care. Increasingly we will want (and probably need) to use data to fully gain the benefits of the many emergent digital developments, certainly in how we use artificial intelligence (AI).

As I write this blog, we are still anticipating that the industrial action will continue until 7am on Wednesday. I would like to say a big THANK YOU to all those nurses, porters, midwives, catering staff, occupational therapists, managers, doctors, and many other colleagues who will have stepped up during this strike in order to minimise any potential harm to patients from occurring. Alongside our communities and neighbourhoods, it is these same folk who, in the coming months, will also be called upon to take the ambitions of the 10-year health plan forward – I have great confidence they will rise to, and relish the challenge.

What’s in a name?

How time flies. Some 50 years ago now, I can remember sitting on buses in downtown Swansea confidently diagnosing my fellow passengers. Of course, then as now, I’m not qualified to diagnose any form of health or illness issue. But back then, with a modicum of nurse training and education, I thought I could. I was wrong on so many levels. That’s not to say that my nurse education was worthless. It wasn’t. It helped me on a journey from Nursing Assistant to a Professor, and Dean of a successful university School of Nursing.

I had a great student nurse experience. It wasn’t anything like today’s nurse education, but I loved the hands-on aspects of my programme. Theory was brought to life by some very wonderful nurse tutors. But it was far from a comprehensive course. I never worked in Urgent and Emergency Care (UEC), which I really wanted to do. I did just three months in a physical care hospital, and my placement was in the acute hospital dentistry department. As a young student nurse, it was a brutal and bloody place to spend time in.

Fast forward a few decades and as a Non-Executive Director, I have been fortunate to visit many UEC departments. UEC departments are often frenetic places. The numbers of folk walking through the front door or delivered by emergency ambulances can, at times, feel unremitting. That said in my experience, UCE departments are where you can see much compassionate care in action. I saw something very similar last week. I was able to visit our nationally renowned Addiction Services, well the inpatient side of the service at least.

It was a wonderful visit and a real pleasure to meet such a brilliant multi-professional team. They deal with some many complex and life-threatening health conditions and work closely with other healthcare providers in acute and mental health care across England. I even got to meet a tortoise, a very happy parakeet, a rabbit and guinea pig; all of whom were part of a pet therapy intervention. I was in my element, and it was clear, so were many of the service users taking part in the session.

A special delight for me was meeting Liz, one of our Nurse Associate's. She told me that back in 1988, I had interviewed her for a job, which she got. She has been working at our Trust since that time and told me she loved her job. I don’t know who had the broadest smile, Liz or me. Nursing Associates were first introduced in 2016. It is a role that bridges the gap between a Health Care Assistant and a Registered Nurse, and much needed.

We are likely to see many more new entrants to the once traditional and (undoubtedly) limited health care workforce, as the NHS 10 Year Plan: ‘Fit for the Future’ begins to gather momentum operationally. Of course, caution needs to be taken to ensure that as these new roles are developed, the scope of practice is carefully regulated. Something that was in the news last week following the publication of Professor Gillian Leng’s report into the role and practice of Physician Associates. Professor Leng is the current President of the Royal Society of Medicine. She had been asked to undertake the review by Wes Streeting (Secretary of State for Health and Social Care) following a number of high-profile deaths linked to the work of Physician Associates. One of which was that of Emily Chesterton. She died, aged just 30, from a pulmonary embolism having been misdiagnosed on two occasions by a Physician Associate.

I feel the need to add some context. I have no wish to defend those responsible for what might have been Emily’s avoidable death. However, according to NHS Resolution, in 2023/24 the cost to the UK of harm or death caused by medical or clinical negligence was some £5.1billion. The greatest number of claims arise from urgent and emergency care, with maternity claims’ costs being the most expensive.

Now every day, there are some 1.6 million individual patient contacts with the NHS (it includes people attending GP appointments, having an operation or those on a follow up outpatient appointments); the majority by far, being with GPs. Fortunately, there are over 1.3 million people working in the NHS who provide for those who need care. Sadly, mistakes will be made that might result in individuals being harmed rather than helped by the NHS. Hence the need to constantly look at ways of making health care safer and safe every time. I guess time will tell as to whether Professor Leng’s recommendations, which includes a change of title to Physician Assistant, will help keep patients safer. I hope so. I also hope her report does not leave us less confident in continuing to broaden further the traditional health care workforce.

A return to the tribe that wears white

Thoughts about the focus for my weekly blogs come from many sources. Top of the list will be things I have read, followed in no particular order by things I might have heard, seen or experienced. I often hear something that piques my interest on the Radio. Radio 4 is my favourite station. The variety of programmes means there is always something interesting to listen to, as I drive. Last week, driving home, I listened to the Radio 4’s PM programme. One of the reports was a follow up to an interview the day before with Melissa Ryan. She is one of the co-chairs of the resident doctors’ committee.

Resident doctors were formally known as junior doctors. Last week they announced they would be taking five days of industrial action later in July. The threat of industrial action results from the government refusing to agree to the British Medical Association’s (BMA) demand for a further 29.2% pay rise. Resident doctors agreed a two year 22% pay uplift last year. This year they have been offered a further 5.4% pay award. However, the BMA argues that when inflation is factored in, doctors’ real-term pay has actually fallen since 2008.

The PM discussion explored measuring inflation. It was a discussion that took me back to my MBA studies when we were taught how to calculate the future value of money and those net present value calculations which we had to do for our capital business cases. Horrible!!!

There are two main ways of calculating inflation, the Retail Prices Index (RPI) and the Consumer Prices Index (CPI). In the UK, since 2008, the agreed gold standard for measuring the rate of inflation, is the CPI. The BMA have chosen to use the RPI. Now to demonstrate why these two different measures are important, I turn towards the independent health and social care ‘think tank’ - the Nuffield Institute - for help.

Comparing changes to pay over different points in time will sometimes give differing outcomes; so will using different measure of inflation. Absolutely so. The Nuffield Trust compared the impact on resident doctors pay since 2008 using both RPI and CPI measures. They have calculated that by the end of this financial year (2025-26), if RPI were used, doctors pay would have decreased by some 17.9%. However, using CPI as the measure over the same period would result in a fall of just 4.7% since 2008.

Now as regular readers of this blog know I try and avoid politics, so I don’t want to delve into the political consequences of untangling and resolving this situation. I am however, interested in the potential sociological consequences that are beginning to emerge. When I wrote my PhD thesis I drew amongst others, upon the work of Melvin Konnor, a brilliant anthropologist.  One of the books he published in 1993, was called The Trouble With Medicine. I urge you to try and get a copy to read, as it is remarkably prescient when thinking about today’s health care zeitgeist.

In the book, he, at one point, describes doctors as the Tribe that Wears White. It was an interesting idea, and reflected the often familial, but definite professional ties that bind doctors together as a single powerful profession. Allegedly, if you upset one doctor, you run the risk of upsetting them all. This hasn’t been my experience, but clearly there is a sense of loyalty to each other not seen in many other professions. We saw this loyalty in action during the previous 11 occasions that resident doctors took industrial action. Consultants and other senior doctors stepped into the gaps left by striking resident doctors. It felt like an act of beneficence that saw their junior doctors exercising their right to take industrial action while reducing the potential harm to patients. There are signs that the social cohesion evident across the medical profession is beginning to splinter.

Notably, the immensely popular professor, TV doctor and pioneer of IVF treatment, Lord Robert Winston, resigned from the BMA last week. He had been a member for 64 years. He noted that taking industrial action now ran the risk of damaging people’s trust in the profession. It was a view echoed by Lord Ara Darzi, who had recently undertaken a review of the state of the NHS. Recent polls suggest there is very little support from the public for further industrial action. Large numbers of people across England are struggling in so many ways. Often people’s lives are fragile and precarious. Lord Winston noted that: ‘strike action completely ignores the vulnerability of people in front of you’.

Melvin Konnor expanded his thinking about who has infiltrated the tribe that wore white, ‘the tribe under study is all of us; doctors, nurses, hospital managers, government representatives, bureaucrats, lawyers, and last but not least, patients, a position that sooner of later includes us all’. The governments recently published ’10 year Health Plan; Fit for the Future’ gives us all a chance to really change the way health care is provided in the UK – I hope we don’t blow this opportunity.

A slow, but a positive journey towards improvement

Last week was an interesting week, for sure. On Monday, I had arranged to visit our Low Secure Forensic services, as I hadn’t been there for a while. The Lowry Unit, as it is known, provides a lovely environment, particularly the outdoor spaces which have fabulous murals on the walls. The two wards were brightly lit with natural sunshine, and were beautifully decorated. The atmosphere was one of calmness, yet there was lots of activity going on. The whole place felt warm and welcoming. I was hosted by Hayley, one of our Matrons. She was a great host and was happy to both let me see anything I wanted and arrange for me to talk to her colleagues.  If culture is set from the top, then Hayley showed how it could be done well.

She was justifiably proud to have started her career as a healthcare assistant, and had over the years worked herself up into her current position. She remembered me from her nurse training at the University of Salford, and told me I had signed her certificate when she graduated. I was kind of proud too that she had done so well. A couple of other colleagues also remembered me from their nurse training days. Sadly, I couldn’t say the same was true, but it was good to hear, that in a small way, I had been able to make a difference.

On Tuesday, Jane and I bought a canal narrowboat. It is the second time in my life that I have done so; a first for Jane. Just to be clear, we are not going to live on it, but will use it to enjoy the plentiful canals up here in the north west of England. Well, that’s today’s decision anyway…  …who knows? My Summer cold, which had started on the Tuesday, had abated yesterday, so I spent the day on our boat, as I started to take it up to our permanent mooring. It was fun. The weather was kind, and I had great company too. It’s a start of the next chapter of Jane and I making memories together.

Wednesday was a washout. My cold was full blown and so it was a Lemsip and life admin catch up day. Whilst it is important to keep on top of life admin, it’s not my favourite way to spend my time for sure. Every day is precious, and I would rather have been in our garden or walking on the beach.

Thursday was a full-on day. I started very early to avoid the traffic, which meant I found myself sitting in a car park in downtown Ashton reading my current book at 6.45am. I was there to take part in the interviews for a new Chair at Pennine Care Foundation Trust, an organisation with whom we have pledged to work more closely and collaboratively with in the future. I wasn’t due to report in until 8.45am, and by the time I walked through the doors, I was desperate for the loo. Thankfully this was a resolvable problem, and I was well looked after.

My part in the selection process was completed by midday and I whizzed back up the motorways to join in with our first ‘All Colleagues Forum’ at the Trust. For the second time in the week, I felt a sense of pride. Some 500 colleagues joined the call and my Executive Director colleagues took us through our revised organisational, people, and care strategies. There was an update on the return of Oliver Shanley, who back in 2023 undertook an independent review into the issues raised by the undercover Panorama programme into poor care and abuse in our forensic services. He is coming back to see how much progress has been made on our recovery journey. And there is some great improvements to show him and his team. There was also a chance to alert colleagues to our Star Awards celebration in October, a night that is always enjoyable.

Later on Thursday, I joined a national call hosted by the Chair of the new (interim) NHS England. A thousand people from across England joined the call. It was an opportunity to consider some of the ambitions set out in the NHS 10 Year Plan, which had been published earlier in the day. This is not the blog to explore the plan, I will do soon, but it was great to finally receive the 168-page document and see the aspirations it contained.

Friday was a day to be out and about. Which is what we did. As I was out and about, I reflected on my Monday visit to the Lowry Unit. I realised what a milestone that was in being able to reopen the service up for new admissions, something the team there have done successfully since late last year. As a Trust, we have moved forward in terms of improving the safety and quality of care we provide, and even if at times it might feel akin to the maximum 4 mph of a canal boat speed, we are moving forward. And that also makes me proud of all my colleagues who have made this possible. A big THANK YOU to you all.