NHS England’s 5 year Forward View is, in general, a bold, grounded and salutary document which sets out clearly the challenges which we all face in ensuring that a thriving system of publicly funded universal health care is in place in 2020, despite the economic and other pressures which face us as a society. It is a document helpfully devoid of political spin which does not attempt to set out detailed prescriptions for how those challenges are met but rather provides a sense of permission for the actions which all of us involved in the system need to take to reshape the way in which healthcare is delivered in this country. It strikes the right balance in pervading a sense of optimism that these challenges can be overcome while arguing for realistic decisions about funding if that optimism is to be justified. The document is the most tangible sign so far of NHS England staking its claim as the leader of the new system and it is creditable that it has decided to do so, working together with the other major players in the post-Lansley NHS.
There were a number of things in the document I wanted to comment on, some where I support what has been said, some where I feel it could have gone further, some where I feel an important ingredient for change has been left out.
First I applaud the strength of statement supporting a commitment to delivering genuine parity of esteem to mental health. Recent announcements around waiting times for mental health have been a welcome first step towards trying to close the gap between rhetoric and reality in this respect and I am pleased to see there is recognition that this must go much further. However I am concerned that behind this promising start there may be a failure to realise the enormity of the task to ensure that people with mental ill health receive the same response at those with physical conditions. It is inconceivable, for instance, that we can close the treatment gap for the 75% of people with depression and severe anxiety who do not receive any form of treatment without a major rebalancing of resources.
In addition it is crucial that, across the NHS, we take a more psychologically informed view of health and health behaviours. There is no artificial boundary between our minds and bodies. Our psychological condition impacts crucially on our ability to recover but these insights are often far removed from how health professionals are trained and from how we organise services to care for patients. While I welcome the emphasis in the document on a more assertive engagement with public health and on earlier intervention to prevent or postpone chronic illness such an approach must also be informed by an understanding of the psychological and social environment in which people are motivated to look after their health. Exhortation and lecturing on their own will do little to persuade people to reduce their weight, drink less or take more exercise.
The document says some important and helpful things about the need to reshape the landscape of care away from the paradigm of the District General Hospital to a world where more care is delivered closer to home in the community but where, at the same time, specialist care is concentrated in a smaller number of centres of excellence. Sensibly in 2014, compared to 1962 when the last blueprint for hospital care was published, it indicates that how transformation is achieved must be a matter for local determination. It is also sensible to suggest that while it is self-evident that we will need, as a result of these changes, less hospital care it may be better, in some cases, to find ways of finding new approaches for existing facilities rather than always entering a toxic debate about closure. As was clearly illustrated to me when my elderly mother was recently hospitalised patients can understand why treatment, especially specialist treatment, may have to be remote but do not understand why care, especially more routine care, cannot be delivered locally in a way which keeps patients connected to their networks of family and social support. A particularly strong point was made in the document about the value of working with the nursing and residential sector to strengthen their ability to care for patients with complex needs.
The shift to out of hospital care clearly needs us to crack the delivery of integrated care. The vision document says some helpful things about the structural options which might help to facilitate this and again rightly stresses that “one size will not fit all”. It is important however that the NHS does not, as its default position, focus solely on structure while ignoring the issues of how it facilitates different models of collaboration between practitioners in the community and the underlying issues of behaviours and relationship which underpin this. It is one of the most abiding lessons of the closure of the long stay mental health hospitals that you cannot just take staff out of an institutional setting of care and expect them to behave in a different way. These questions as much as structural and financial ones need attention.
Finally I welcomed the recognition in the document of the need for the NHS to be working not just in the community but to be of the community. So there was an important reference to the role of the NHS as a local employer and of its responsibility to look after the health and wellbeing of its workforce. There was a healthy message about the opportunity to work more closely with the voluntary sector who can, at times, have a reach and impact which the NHS cannot replicate and I welcomed the emphasis on volunteering and working with carers and families. A greater emphasis on public health and early intervention should also see the NHS concerned not just about what it does itself but how it can support other organisations such as schools and employers to manage health issues.
It seems a feature of our digital age that the lifespan of reports and strategy documents seems to be shrinking and it will be interesting to see how frequently this document is quoted in 5 years’ time. It is, today, a welcome contribution to the debate, running with the grain of debate about the nature of the problems facing us, encouraging innovation, not over promising delivery and setting rather than following the tone of political debate.
There is no doubt a challenge ahead of us to save the NHS but I accept the premise of the document statement that it is one that with the right effort and encouragements we can meet.
Doing my job I am lucky to get to go to the launch of some of the excellent publications produced by members of the clinical team at the Tavistock and Portman. A book I have just finished reading is “The Good Life” by Graham Music, a Child and Adolescent Psychotherapist who has spent a career working with troubled children and adults. As well as being a tour de force of the current evidence on the psychology of altruism, the book reinforces the moral case for doing what we can to create the conditions for happiness and wellbeing and for supporting those individuals whose early life experiences are traumatic and destructive.
Graham’s argument is that empathy and altruism are natural instincts of the human species, which emerge at an early stage in human development and are reinforced by the development of secure attachment with parents and other caregivers. He also demonstrates, as Aristotle concluded centuries ago, when we feel good we are likely to do good and, by contrast, stress in our own lives can reduce our propensity to help others.
Our instincts towards “goodness” are not exclusive. We are also programmed to act selfishly to protect our interests and those of our group. Those instincts are not always bad and have served the human species well over our evolution but there is a question of balance and for recognising the importance of the conditions which promote our better side.
All in all Graham’s book and the science he explains are powerful arguments for policy makers and others giving more attention to issues of child development and adult wellbeing. From time to time this has registered in the public debate but without leading, despite the rhetoric to many fundamental shifts in approach.
Amongst many there are three particular areas of public policy which are worth looking at in the light of this analysis.
The first, and probably most significant, is what we do to support children’s’ early years to encourage the healthy development of the greatest number of children and reduce the level of harm incurred by those children who are victims of abuse or maltreatment.
The focus should be both on parents and children. Parenthood, despite all the other social and economic advantages I enjoyed, was the one of the tasks in life I was personally least prepared for. I learnt on the job and it took me years to feel confident in the role. I was lucky with the support our received from my family and social networks. Others are not so well placed.
You cannot necessarily teach parenthood in the classroom but you can do more to support parents whether through generous provision for parental leave, targeted evidence based programmes such as the Family Nurse Partnership which support young mothers or the wider provision of parenting programmes and advice. Support for when couples experience difficulties in their relationships is also crucial given the immensely negative impact which parental separation or dysfunctional parental relationships can have on children. While I have no desire to return to a past where many, particularly women, were trapped in lives with loveless or cruel partners I also believe that we underestimate the value of support those who wish to mend their relationships.
We also need to have an honest debate, led by young people themselves, about what constitutes a good childhood. Every age has its myths about childhood and, whatever society does, children can have happy or unhappy lives depending on their own circumstances. Nonetheless there seems no doubt that there is greater pressure on the current generation of young people, whether in relation to academic achievement, body image or peer pressure. This in it is turn is leading to an undeniable increase in the incidence of mental health problems in children and adolescents.
The second area is the ongoing need to look at the overrepresentation in the criminal justice system of people with a history of stunted emotional development, especially as a result of childhood abuse or trauma. Despite occasional rhetoric to the contrary we are still happy to be tough on crime but not on the causes of crime. As well as supporting parenting and healthy child development there is a case for interventions to address mental health problems with their roots in problems with attachment and other issues with childhood attachment. While I recognise the case for strengthening the formal evidence base, practitioners like Graham see the impact which long term psychotherapy can have in helping people with significantly troubled pasts to improve their social functioning and reintegrate with society.
The final area is the wider appreciation of wellbeing as a dimension of public policy. This has its critics amongst those who are wary of those who pretend that teaching people the techniques of mindfulness can be an effective substitute for resolving more fundamental issues of deprivation or providing effective and appropriate mental health services for those in distress. Increasingly I believe, however that wellbeing does matter for public policy alongside strategies for economic growth and that there is a roll for national and local government to measure wellbeing and develop strategies for increasing it.
A role for the state however does not take away responsibility for individuals or wider civil society. The decline of organised religion, at least in some parts of our society, has created a space which other forms of philosophy, belief and community must be encouraged to fill. As individuals we need to give more priority to understanding ourselves and promoting our positive mental health and wellbeing.
The Greek philosophers saw the good life as the central tenet of human knowledge and enquiry. Graham’s book reinforced, from a scientific perspective, my belief that everyone is born with some potential for good and that there are interventions we can make, most especially in childhood to give individual the best chance to realise that potential. We must make this a central tenet of debate and priorities in our own society.
The Good Life – Well-being and the new science of altruism, selfishness and immorality by Graham Music is available at http://www.karnacbooks.com/Product.asp?PID=35203
I had the privilege yesterday of joining a discussion with David Dalton, Chief Executive of Salford Royal Hospital, in particular focusing on the inspiring work he has led around improving patient safety and quality.
I was really struck by what David said about the start of his journey, that you cannot really improve safety if you are not honest and transparent in the first place about the current state of affairs and the intrinsically risky nature of healthcare. Given the number of patients seen by the NHS, harm whether avoidable or otherwise, is inevitable and as the providers of care we must be honest with the public about that fact.
There is a growing and welcome move in the NHS towards greater transparency which I fully support. Initially organisations and individual teams and practitioners are very nervous about publishing data about performance and, in particular, safety and data can always be misinterpreted and used out of context. However in general, as I once heard it put very eloquently, publish and be damned is the right approach and the more you publish the less you will be damned as commentators and the public become better educated about the context from which to judge individual performance and events.
Transparency also helps at the local level so again I was impressed with what David said about the fact that individual wards in the hospital will post data about the most recent incidents and other aspects of performance. There is an example to follow here from food hygiene. The practice of requiring restaurants and other food outlets to publish their food hygiene ratings prominently where customers enter the premise normalises the issue and creates an important pressure on those who are not complying with standards. Done appropriately the same approach can work in healthcare normalising the general run of performance and creating an incentive on those who have issues to address to do so.
A second theme of the discussion was about learning. My experience of healthcare is that when things do go publicly wrong considerable effort is put into investigating what happened, establishing root causes and identifying lessons learnt. Such investigations can often be quite emotional searing for those involved and that, if an avoidable fault is discovered, my experience is that there is a genuine desire for making sure that it doesn’t happen again. Yet in large complex organisations with a constant turnover of staff and leadership those lessons can easily be lost. A learning culture is an easy aspiration to make but one which is difficult to deliver in reality.
There are two approaches which I believe can help.
First is the use of decision support. While I was at NHS Direct, which used decision support routinely in the delivery of real time clinical care, I was struck by how powerful the system could be in helping to disseminate lessons from those cases where things had gone wrong. 15 years later the use of decision support in clinical is still relatively uncommon and I wonder how many lives might have been saved if it had been adopted more widely.
Critics will of course say that medicine does not always lend itself to computerised algorithms and that may to some extent be true. However the clue is in the name, decision support is there to support the clinician not take their place. However there must be advantages in bringing to the clinicians attention, at the point of a decision, key information including any factors from adverse events which might impact on what they do.
The second strategy rests in the power of stories. My time as the leader of a patient organisation convinced me of the power of stories as a vehicle for changing attitudes or behaviour in healthcare. Personal stories not only convey the facts of a situation they also connect us with the emotions of those who were involved. That emotion can be the most powerful factor in getting us to engage with what has happened and what it might mean for our future actions. While circulars and guidelines and more factual presentations are important , stories and their emotional impact are a relatively untapped approach to help us understand and disseminate the consequences of when things go wrong in healthcare.
The final point at the end of our conversation was a sense that this was the right conversation for us, as a group of health care leaders, to be having. All of us had some personal experience of what happens when things go wrong. We could have been talking about money or structures or integration or whole load of other issues which impact on the working life of a NHS Chief Executive. However if we did n’t feel strongly about safety and the avoidance of harm and were n’t interested in what we could do differently to address those issues you could argue we were in the wrong business.
There is the old joke of what do you call a person who only speaks one language – an Englishman. It may be a stereotype but it’s probably never been truer as the number of students studying modern languages at GCSE, A Level and University continues to decline relentlessly. More than the lack of the knowledge itself I am always grieved by the contempt which is sometimes shown in this country to other languages: their uselessness, their incomprehensibility, the outrageousness of speaking them on the streets of London.
As a person of Welsh descent brought up in England, I have always had an interest in languages and admired those who were fluent in more than one. For the Welsh, more so than the Irish or the Scots, the preservation of our distinctive and ancient language has been intimately tied up with our sense of national identity. There is a Welsh saying “gwlad heb iaith, gwlad heb galon” a country without a language is a country without a heart. It is if the language carries a great part of our national and cultural DNA to be passed on from one generation to another. It is one of the achievements of my adult life I am proud of that I’ve been able to ensure that I am not the first generation of my family not to speak Welsh.
But in additions to the specifics of my I might wish to learn the language of my family, there are good general reasons for being able to speak more than one language.
Sometimes it is useful. While I think the utilitarian argument is often grossly overdone in respect of any form of educational activity there are times when it can be directly helpful. Although in my own lifetime the ability to speak English (or rather American) has spread enormously, certainly in Europe, not everybody speaks our language and if you want to quickly go about your business being able to say something in the local language can be useful.
But if the strictly utilitarian was the only tests then I think the decline in the study of languages might be justified. However there are other reasons.
The first is the sheer fascination and beauty of different languages. Learning other languages and how they describe both the commonplace and the special is like seeing the world in colour when you have been used to seeing it only in black and white. You appreciate nuances of meaning and appreciation which are invisible when only looked at through the lens of your own native tongue. The English say “Indian Summer”, the Welsh say “Small summer of Michaelmas”. We both refer to that occasional blast of late summer weather which we experience at the end of September.
This is heightened when you can appreciate the links between different languages. The words in each language which are related to each other, the words they have more explicitly borrowed from each other. Our word triumph which comes from Etruscan through Latin, alcohol which comes from Arabic, kiosk from Turkish. A knowledge of other languages can often be a key to understanding and communicating better in your own native tongue.
The second and, for me, most significant reason is one of empathy. By learning someone else’s language you acquire not only an understanding of the practicalities of their life, you also get an insight into their psychology and at times their soul. It is possible to learn some things in translation but things can also be lost in translation. Hearing and reading in the original language adds a greater depth of understanding which in, most cases, is well worth well the effort. Diversity is the delight of our species and languages are the ultimate expression of that diversity.
Finally if you are not convinced by any of the arguments above there is one left. The mental effort of learning other languages is good for us. Researchers think that the ability to speak another language might be a protective factor for the onset of dementia. So two might indeed be better than one.
The thing I learnt most strongly when I joined a mental health charity nearly 8 years ago was that stigma and negative attitudes towards mental illness added an enormous burden to people affected by mental health problems and their families. Indeed it wouldn’t be overstating the matter to see stigma as the single biggest obstacle to improving the outcomes for those individuals.
I have always stressed that there were three reasons for this. First of all, stigma impacts dramatically here and now on the life chances of people with mental health problems. It prevents them getting jobs, it encourages social isolation, as friends and even family offer rejection rather than support, it leads to people getting a second class response from public services as is evidenced by the appalling physical health inequalities experienced by people with schizophrenia and other severe mental illnesses. Second, stigma and the fear of mental illness, prevents people being open about mental health issues and from seeking help. At the same time, it closes down the channels of peer support which sustain us through many other types of adversity. Finally stigma cuts off the public debate about mental health which, as is clear from so many other issues, is the engine house of getting politicians and others to change the system or make investment in better services.
Things are changing and my proudest moments as a mental health campaigner was to have been associated, while at Rethink Mental Illness, with Time to Change which over the last 7 years has made a very significant contribution to combatting stigma and changing attitudes for the better. Through social marketing and a range of local engagement activities Time to Change has helped to deliver a statistically significant shift in public attitudes and a reduction, in some areas of life, in the reported experience of discrimination.
Just as importantly Time to Change has not done this on its own but has successfully drawn on a wide range of organisations in communities and amongst employers to help spread the word and share the task. A clear mark of this has been the more than 200 organisations, in all sectors of society, who have signed up to the Time to Change pledge and made their own commitment to support the fight against mental health stigma. I am delighted that today my new organisation the Tavistock and Portman NHS Foundation Trust will be signing the pledge.
Signing the pledge is not a mark that we, or anyone else, has got everything right but it is a sign that we care and that we are prepared to commit focus, effort and resources to ensure that people who use our services and their families do not experience stigma and that we are prepared to welcome and support staff and students who have their own experience of mental health problems. Above all we are saying loud and clearly that this is something we are prepared to talk about and consider no differently from any physical illness or any other issue.
While I am delighted my own Board has so enthusiastically embraced this agenda and committed to signing the pledge and the resulting action plan, I am disappointed that so far so few NHS organisations have engaged with this agenda. There are honourable exceptions but in general it is fair to say that the NHS has been slow off the mark to take action to stamp out stigma and discrimination towards people with mental health problems who use it services. It has also been slow to recognise the impact which mental health problems have on its own workforce and to match the “best of class” good practice which employers in other sectors have followed in creating a mental health friendly workplace.
This is disappointing in its own right but it’s impact goes much further when surveys of the experience of people with mental health problems indicate that health and social care services can be one of the most significant sources of stigma and discrimination and one which has shown the least improvement in recent years. Behind the statistics are some terrible stories or people who have been treated judgementally when they have presented with suicidal thoughts or following self-harm or whose physical health needs have been overlooked because they are seen, inappropriately, as a consequence of their mental health diagnosis.
There has been much talk in recent years about the idea of “parity of esteem” between mental and physical health. If the NHS is really serious about delivering on this, one very good place to start would be for all NHS organisations to take the issue of mental health stigma seriously and commit to signing the Time to Change pledge. This is not beyond us, even in times when resources are badly stretched.
The NHS is one of our most treasured national institutions but it is put to shame if it is not prepared to challenge negative attitudes towards mental illness. It is time to change.
Details of Time to Change and how to commit to the organisational pledge can be found at the following link:
One of the most interesting issues I have worked on since returning to the NHS has been chairing a group of providers working together from across the statutory and voluntary sector in City and Hackney to design and deliver a system of integrated care for some of the most vulnerable patients in the area. Last Tuesday we sat down to review how our system would work when presented with some of the real life situations faced by patients and clinicians. It was a fascinating and productive afternoon and drew out, for me, some important and more generalisable lessons about what needs to be in place if we are to deliver effective models of out of hospital care which deliver better outcomes for patients and avoid or reduce the occasions on which patients are unnecessarily admitted to or detained in hospital.
The first was the frustration of not being able, routinely, to share information in a timely manner about patients’ history, needs and preferences. In the absence of this it can be all too easy in a crisis situation for an ambulance crew or others to admit a patient as a way of avoiding risk. The availability of the care plan at the point of care might make all the difference if that gave clear details of a pre-established crisis plan or of another source of advice with whom the decision about the risk of leaving a patient at home could be shared. If we cannot share the information electronically (and I think it is still a major indictment of a supposedly National Health Service in the 21st century that we haven’t cracked this) then there must be a place for approaches such as “Message in a Bottle” where a care plan is left in the patient’s home with a visible indication to visiting practitioners of its existence.
The second lesson was about the value of working with patients and families in advance of a crisis to discuss with them their preferences and to work out who to contact and how best to manage when a difficult situation did arise. This kind of preventative work ought to be the heart of effective care planning and can do so much to ensure that all parties are prepared in the event of a crisis when decision making inevitably tends to be less than perfect. It also reflects the opportunity to build up the kind of trust between patients, families and health and social services which make shared risk taking that much easier to deliver.
Some of the cases we considered highlighted the challenges of fitting care around the, sometimes messy, complexities of patients’ lives. There is a difficult boundary at times for practitioners working in circumstances where they have concerns about individual’s home circumstances. However either ignoring those issues or being too judgemental helps no one and where, for instance, such concerns turn a routine day admission into a hospital stay of 4 months the system is not working. Resolving such issues often play better to the skills of social work and the voluntary sector and they need to be given the opportunity to work with patients to find a way forward which works.
Time was often the key factor. Where a range of interventions whether clinical, or as often social or practical, could be accessed quickly then it would be possible to keep a patient at home. If not then a hospital admission inevitably became the default position. Alternatively the issue of time related to the ability for busy clinicians to spend the necessary time when required to contact other services and negotiate the necessary support. At times, even for the most dedicated clinicians, that became too difficult and, again, a hospital admission became the only viable option. In City and Hackney we have recognised the need for including in our model individuals who have the capacity and authority to resolve such issues.
The final lesson was in the very process we were engaged in. Facilitated multi-disciplinary discussion of individual cases helps identify what works and does not work in the way in which practitioners and organisations work together. Where this is done in a supportive and “no blame” manner and where action can result from the lessons learnt then it is possible to organically improve the integration and outcomes of care. Again such a “learning system” is central to the approach we are trying to put together in City and Hackney.
For me this was a good week for the integration agenda. The excellent report of the Barker Commission, published on Thursday, set out a compelling case for addressing the structural dysfunction of separating health and social care. Tuesday’s workshop highlighted for me how, at the local level, that when practitioners and managers are focused on patients not on organisational processes and interests real steps forward can be taken. That’s got to be the goal.
Like many mental health conditions, depression suffers from a stereotype. If schizophrenia is characterised by an inappropriate association with violence, depression can tend to be trivialised as something which is within an individual’s control to “pull themselves together” from – more of an issue of attitude than a real illness.
As Robin Williams’ experience and many powerful testimonies from people who have lived with depression show all so clearly, nothing can be further from the truth. To be stuck in the depth of depression is a truly awful place to be, a place which can lead someone to consider that taking their own life is preferable to continuing to live through what they are experiencing. Whether in touch with mental health services, or more likely not, people with depression will account for a large proportion of the more than 4000 people who take their own life in this country each year.
Even if not as extreme as that, depression can be a profoundly debilitating condition which significantly impacts on an individual’s quality of life, their ability to hold down a job, their ability to make and retain relationships and family life. From a societal perspective, depression is one of the largest causes of health related unemployment as well as impacting on the productivity of those who are able to stay in work.
Furthermore there is a strong link between depression and long term physical health conditions and where there is co-morbid depression it is likely that outcomes for individuals will be much poorer. So for instance, people living with diabetes are 2-3 times more likely to have depression than the general population and patients with chronic heart failure are 8 times more likely to die in 30 months if they have depression. All in all, poor mental health in this population is estimated to cost the NHS at least £8 billion every year.
Like many conditions, however, depression presents itself on a spectrum. For some people depression can be a self-limiting condition, the symptoms of which they are able to manage without medical intervention. For others medication, CBT or other short forms of talking therapies can provide effective relief of symptoms. However for a significant group of people symptoms are severe, long term and deeply disabling.
The Government has taken some action to address the individual and societal impact of depression and the introduction of the Improving Access to Psychological Therapies (IAPT) Programme in 2007 has made an important start to improve access to talking therapies for those affected. Those such as Lord Richard Layard and others who have campaigned and cajoled Governments of all hues to invest in this programme deserve much credit.
It would however to have been criminal not to accept this case and there is much more to do. 70% of people with depression do not have access to treatment – just try repeating that sentence with cancer rather than depression in the sentence. For those who do get access to treatment, waiting times can still be too long – it was very saddening to read, last week, the account of a father whose son with depression took his own life while on waiting to access the IAPT service.
Furthermore the options for people with depression are still too limited. Cognitive Behavioural Therapy (CBT) is a good intervention which offers benefits for many patients. However it does not work everybody and it is still very difficult for people, especially with more chronic and intractable problems, to seek a wider range of longer term therapies. There is the option to use the new right of choice in mental health introduced this April to address this but it is still hard to see how this would work in practice and how funding would flow to support patient preference
So this is yet another illustration of the scale of the challenge which faces Governments and the NHS if we are to deliver to worthy intention to create a parity of esteem between physical and mental health. Given the numbers affected (it is estimated that 8-12% of the population will experience some form of depression in any given year) and the impact the condition has both on those individuals and our society and economy more generally this is a challenge which cannot be ignored.
Picture thanks to Emma Scutt – @emmylouscutt