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Mums

 

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It was Oscar Wilde who gets Lady Bracknell in the Importance of Being Earnest to quip that “To lose one parent may be regarded as a misfortune; to lose both looks like carelessness.” Yesterday, I said farewell to my mother, just over a year and a half after the death of my father.

In offering comforting messages of support in the last couple of weeks, lots of people have highlighted how significant is the loss of parents, whatever the relationship you had with them and whatever the age they have passed from you. Indeed, it is.

I have written before about my father, but I wanted, in this blog, to pay a particular tribute to my mother, a woman who never wanted to blow her own trumpet. In doing so I also want to celebrate the fundamental role all mothers play in shaping who we are as individuals.

My mother was born in the West Midlands in 1927 where she lived for nearly all of her life until she moved into a nursing home in York after the death of my father. Some of her down to earthness and modesty reflected the soil on which she was raised. They are both qualities I have always admired in the city I, too, was brought up in.

Mum started her working life as a secretary on the Railways. Despite having gone to a Grammar School and done pretty well she had not been encouraged to stay on at school nor go to University as her brother had. Mum was brought up in an era when there were still very clear barriers for women’s careers and in my generation, or that of my children, her life might have been very different. As a great animal lover, she always said her ambition would have been to be a vet. Perhaps today she might have realised it.

Mum did get the encouragement, however, to train as a primary school teacher. She worked with different age groups but ended up in a pre-reception nursery class. She was an excellent teacher, diligent, committed and patient and genuinely interested in the young people in her care, and, in particular, with those children experiencing the greatest difficulties.

It was through teaching my mother met my father. They were married for over 65 years, a massive achievement based on a loyalty to each other which was absolute through sickness and health, good times and bad. As Mum said to me in the most difficult conversation, I have ever had, just after I had had to break the news to her that Dad had died, she had never had eyes for another.

Mum was a brilliant grandmother. She brought to the role a mix of her skills as a mother and a teacher. Alongside my own feeble efforts as a parent, I was in awe of how she enchanted my children with her kindness and calm sense of authority. My wife and I could never have coped, as working parents, without her selfless willingness to drop everything to come to look after the children at the drop of a hat. My children loved her to bits.

As a mother I owe her so much for what I have been able to achieve in life and for what I have become. There was a sense of her always being there and holding me in mind and she was unstinting in her support for what I wanted to do. While my father might have often been the front man for announcing their intentions as parents, I was very aware that, behind the scenes, it was my mother who had persuaded him of the importance of some sacrifice or other they were willing to make.

In my professional life I have been very aware of the significant impact which the lack of secure attachment, whether through bereavement, separation or other factors, can have on the mental health, wellbeing and life chances of young people. There are few things which I believe in more than the importance of us, as a society, investing in the opportunity of all young people to have a good start in life, especially in those cases where young people lack the advantage of the secure and loving home, like the one from which I came.

One’s mother is, in most cases, the single most important person in one’s life.  At times in the last fortnight, I have struggled to accept that she has gone. Not because I doubt the fact of her death but because her voice and influence are so much part of who I am. I have a relationship with her which goes back before my earliest memories and will last well beyond her physical passing.

Yesterday afternoon as we sat, after the funeral, outside York Minister we spoke to my son, who, due to Covid, had been unable to join us at the funeral. He had held his own ceremony at home to mark his grandmother’s passing. He told us that as he took out a book of poetry to read, an uncashed cheque from my mother had fallen out of the book. It struck me as a wonderful metaphor of how, even from beyond the grave, she had us in mind. Then I thought of who in the world I would have most wanted to tell that story to.

Lockdown Lessons

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Steadily we are beginning, as a nation, to emerge from Lockdown and regain some of our freedoms of movement and association. It will take a time for this to happen, and there may be steps back, but the tide has definitely turned. This week I made my first trip out of London for over two months and, for the first time since Lockdown, worked two days in a row in the office.

The last two months have a very unique time and have made me think a lot about what is most important in life. My experience has, in many ways not been too bad. My wife and I may have had the virus but, if we did so, we had it very mildly. I have continued to work, in a role which, while challenging, has been also very fulfilling and, for the most part, I have been able to cope with the constraints that have been imposed on me. There have also been some positive compensations.

It is a long time since I have spent such a long time in one place. Apart from a weekly trip to work and slightly longer cycle at the weekend, I haven’t wandered more than a mile away from my front door. It has been good to spend so much time at home, something which I sometimes struggle to do in normal times and learn to appreciate what is on my doorstep.

A very special part of Lockdown has been what my wife and I call our “constitutional”, an hour’s walk, before the start of the working day, on Wandsworth Common or along the banks of the mighty Wandle, our local tributary of the Thames. This has been such a lovely time, both for the exercise, the opportunity to appreciate the beauty of nature and to have some quality time together. That special hour has been front and centre part of what has helped me cope psychologically with everything else which has been going on. It would be so good if it were possible to make it part of my routine on a long-term basis. Whatever is possible I do want to reduce the amount of travelling I do and spend more time, by choice, in the place I live.

While there are lots of issues to work out in how we return to the new normality there is no doubt that there is a great case for resetting the balance between “the office” and home working, reducing the need for travel and its consequent impact on the environment. With this also comes opportunities to reset the balance between work and personal responsibilities. Ironically, despite physical distance, Lockdown has forced me to spend more time with my family and friends in ways which I would been keen to continue in the future. While, like others, I have enjoyed something of a surfeit of virtual meetings in recent weeks, I definitely think they will continue as part of my professional and personal life.

This points to what has been another great positive of the experience of Lockdown, the strengthening of community spirit and activity. Whatever differences of view are now emerging, the first phase of the pandemic was characterised by a striking level of compliance with rules of Lockdown and the changes in individual behaviour it required. In some cases, this has meant very significant sacrifices and heart-breaking personal dilemmas such as experienced those who have not been able to be with loved ones at the end of their lives.

For me personally the hardest part of the Lockdown has been to witness, at distance, the decline of my 92-year-old mother who has dementia and who lives in a care home. Despite the efforts of the staff in her home, the Lockdown and the loss of family and social contact has dramatically accelerated her physical and mental frailty. That decline may, at some time, have been inevitable, given her condition, but it has been very hard to witness it at the end of a Skpe call.

Along with sacrifices there have been many acts of solidarity. While NHS and care staff have been at the forefront of recognition, there have been many groups of workers who have gone the extra mile at personal risk to keep things working. The Thursday evening clap has been an important act of recognition for these groups but one which I hope is not forgotten when crucial decisions are taken, for instance about the future of social care and about low pay.

How much of this collective spirit we will be able to keep we will have to see but my hope is that the shared experience we have all been through in the last couple of months will lead to some long term shifts in attitudes. The strengths and weaknesses of our response to the pandemic have consistently pointed to the value of a strong and sufficiently resourced public infrastructure. I hope a commitment to support a level of higher taxation to see us through the crisis, reward some of the low paid groups who have been central to our response and tackle some of the concerning issues of the inequality which the pandemic has highlighted will be a lasting legacy of this crisis.

The NHS and post war welfare state we remain proud of grew out of the collective experience of suffering in World War II. What can our generations make out of Covid 19?

 

Unlocking lockdown

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As a country I think we have managed the period of lockdown pretty well. Some relatively clear, relatively fair instructions about what we need to do in response to a national emergency have enjoyed a high level of compliance. We have, on the whole, endured significant restrictions of personal freedom with a good grace and with a minimal need for enforcement. We have applauded the work of key workers, not just NHS staff but all those who have continued to have to work, despite some personal exposure to risk, to keep essential services going. Kindness has been more in evidence than meanness and that best of all British qualities, our sense of humour, has been at the forefront. For the most part,we have kept calm and carried on.

Now comes the difficult bit. Whatever your views were on its content, the Prime Minister’s speech last Sunday marked the start of the process to move us out of lockdown and to restart the economy while, of course, remaining vigilant about a virus which has not yet gone away and which, in any case, is expected to come back in second and subsequent waves.

In this second wave messages are inevitably more mixed as we start, as the Americans say, to have “to walk and chew gum” at the same time. In the last couple of weeks, there have started to be a series of stark of stories about the economic consequences of the pandemic with worrying news of large-scale redundancies. Furthermore there have been some eye watering statistics (the starkest downturn in economic activity in this country since 1706) which highlight the danger that an economic shock on this scale will lead to a deep and damaging period of recession akin to that which happened in the 1930s.

There is a real seriousness about the economic issues which sit ahead of us. It is disingenuous to argue that this is just about the interests about wealthy capitalists. However we try to moderate it, a major economic downturn will be bad news for all of us, for the pubic services we value and depend on, and most of all will be worst for the poorest and most vulnerable in society.

The same is true for the social and psychological consequences which will emerge as a result of individuals’ experience of illness or bereavement, lockdown or resulting economic distress. We will need the capacity to mobilise resources proactively to address these.

Yet all of this needs to happen alongside sensible action to protect personal safety and manage the spread of the infection.

For me there are a number of important principles to govern how we should progress.
First, we need to acknowledge that both saving lives and reviving essential economic and other activity are equally crucial in the next phase of the crisis. Both perspectives need to be balanced in a more nuanced set of decisions about what we should do as individuals and what public activities are opened up. We need to develop narratives which help unify rather than divide opinion. Government needs to lead this but can not to do so on its own.

The second is to realise that life will not go back to normal with any speed. I was struck during the celebrations of the anniversary of VE day by the some of the reminiscences of how it felt on the original VE day to realise that, in Europe at least, war was over and that a palpable source of danger had passed. We do not have the same sense of relief today. The risk of infection is declining but will not disappear and as a result we have to continue to accept some limitations in our freedom of action. Thought needs to be given to redesign aspects of public life in ways which facilitate social distancing and reduce risk. At the same time, we have to accept that we can not guarantee total safety, just as we cannot, in reality, in many other areas of life.

The third principle relates to how we support the most vulnerable in society. We need to recognise that the virus has not been even handed in its impact and that some groups, in particular poorer and some BAME communities have experienced a disproportionate level of mortality. We need think carefully, and systematically, about we can minimise those risks as we take measures to open up society.

We also need to think about those individuals we have physically shielded in the first phase of the pandemic and consider how we can also address their psychological and emotional needs while still protecting them from the risk of infection. The lowest point of my experience of lockdown has been to see the decline in my 92-year-old mother’s wellbeing as she has been cut off from contact with her family.

My final principle is on the need for hope. It has been very lovely to see all the hand drawn rainbows in windows up in our street and neighbourhood. The rainbow is a wonderful image of hope amidst trouble which reminds us in the beautiful words of Dame Julian of Norwich

“All shall be well, and all shall be well, and all manner of thing shall be well.”

We need to shift the curve too for the mental distress generated by Covid 19

 

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There has been much concern about the level of mental distress which may emerge out of the Covid 19 pandemic. We know, both from the specific evidence coming back from China and Italy about this pandemic, but also from the general experience of many other major traumatic events, some of the issues which are likely to emerge. In this case, it is likely in addition, that there will also be the impact of major economic dislocation. All of this was well described in a recent position paper in the Lancet.

It is one of the gains from all the work we have done in reducing the stigma around mental health problems that we can be much more open talking about them in the current context. In the past we might have ignored such issues or left them undealt with them until they presented in more extreme forms of distress. That said, how do we ensure that we can respond as effectively as we can in the current circumstances to an anticipated surge in requirements for help.

My argument, in this blog, is that there is much to learn from the public health strategy of “flattening or shifting the curve” which has been applied in managing the physical health consequences of the pandemic. We should indeed expect and plan to respond to a significant increase in presentations but we can also take steps to reduce the level of need for clinical level interventions so as to ensure services are not overwhelmed and that those with the greatest needs are able to get help in a timely way.

There are a number of elements to such a strategy.

The first is not to confuse, in our thinking, distress and trauma with enduring mental health problems which require ongoing clinical treatment. There are many groups who are going, in differing ways, to come out of the pandemic with experiences of significant distress whether as a result of social isolation (likely to be particularly acute amongst some of the vulnerable groups who have been shielded to protect their physical health) grief or bereavement, their experience as key workers or the impact of sudden economic dislocation and loss. Such experiences are risks factors for the development of mental illness, but they are not necessarily translate into ongoing issues and we can intervene to reduce the resulting burden of enduring problems.

To do so we need an effective and dynamic public mental health strategy, co-ordinated at national and regional level and informed by research but delivered locally in communities and organisations to support messages about how individuals protect their wellbeing and process some of the difficult experiences they have been through. There are many good digital and other resources to help support individuals but there is also a need, as has been the case in physical health, clear and consistent messages about what to do.

Notwithstanding what I have said before about stigma, one of those consistent messages will need to be to encourage people to see as normal and talk openly about any distress they are feeling. Sharing issues in a supportive environment is often an effective first line of response. This message, though, needs to be presented through a wellbeing lens which avoids pathologising distress and which supports personal and collective agency in looking after our mental health. Strong consistent messaging is crucial here, as with physical health, to counter some of the unhelpful and alarmist messages which circulate in the media.

The second is to recognise the importance of segmentation of audiences and need. Experiences of distress will manifest in different ways for different groups and understanding context will be crucial to responding effectively. Children and young people are a good case in point. There will be some shared experiences of lockdown for all young people but for some distress will be greater because lockdown has triggered or exacerbated underlying risk factors, for instance in relation to domestic violence, abuse or neglect. Young people with some neurodevelopmental issues may have found parts of the experience of confinement especially difficult and may also struggle with the return to school when that happens. In looking at the health and care workforce there will be the need to focus differentially on a range different groups not just those who have been working “on the front line”.

The third is to enable an integrated response between public health interventions and service responses. We can work together around events such as children returning to school to combine effective programmes of support to young people, families and teachers with clear routes on how these with more severe difficulties are offered help quickly. Services need to stratify the populations known to them to identify those who might be at most risk and target help, where possible, proactively. We need to very mindful of the impact of the pandemic on inequalities and where differential experiences may have potentially lifelong consequences, for instance in terms of poorer educational or employment outcomes and greater vulnerability to chronic mental health problems. Statutory providers in the NHS and local government should work with partners in the voluntary sector to ensure the best use is made of all the resources available to support those in distress.

Our strategy needs to be innovative and adaptive as services have shown themselves so capable of being in the first weeks of the pandemic. We need learn from experience and be prepared to develop new models of service to meet new needs and to respond to existing needs presenting at greater scale.

My final point is about longevity. It is clear that we will have to work around different phases of the pandemic with different needs and responses at each stage. That applies as much as to psychological consequences as it does to physical ones.
What we also know about trauma suggests that it is not necessarily at the outset that the most difficult issues are experienced. Indeed, ironically, it may be at the point of return to some kind of normality that some individuals are most at risk. What we put in place must be sustained and take account of the different waves of psychological strain which may be experienced. This also applies to resources and the same promises which have been made to do what it takes to help the NHS manage the pandemic must be apply equally to action taken to manage its psychological consequences.

Beyond that, indeed, there is a stronger message which is that we must take the experience of the pandemic to make sure that we make a proper focus on mental health and wellbeing a central and integral feature of how we go about things whether in health and care services, schools or workplaces. Just as shell shock a hundred years broadened, and to some extent normalised, the public understanding of mental distress we must use the current collective experience to put mental health at the centre of our response.

War Doctor

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It’s been one of the gains of lockdown to have a little bit more time than usual for reading. One of the books I have been able to finish is War Doctor, the autobiography of David Nott, a surgeon who has combined a career in the NHS with fantastic humanitarian work in some of the most troubled conflict areas of the world. It is a compelling story, told with enormous honesty, both about the situations he has seen and worked in but also about his own emotions and conflicts. This is not just a tale of a hero, which he undoubtedly is, but also of the psychological strains which are entailed in carrying out such a role and in managing the tensions between the world of humanitarian work and that of normal life. It is all the richer an account for that level of openness.

The story ranges across most of the significant areas of international and civil conflict of the last thirty years: Bosnia, Sierra Leone, Afghanistan, Iraq, Libya, Gaza and finally, and most poignantly, in Syria. Most of his assignments are with international aid bodies such as Medicins sans Frontieres, the Red Cross or Syria Relief. The conflicts are all ones which, in one way or another, I am familiar with but without, often, much detailed knowledge of what happened and their impact on the populations affected.

The clinical descriptions are fascinating. Nothing brings the horror and futility of war more into focus than to read the details of the damage which modern weapons can cause to the human body. It’s not just that bombs and bullets kill people, but they do so in ways which are so terribly horrific and gruesome. Furthermore, since the First World War, the burden of war has been increasingly borne by civilian populations: men, women and very often children.

In some cases, the author describes some phenomenal lifesaving interventions which despite the rudimentary nature of the facilities available, succeed in bringing patients back to life, and even to health, from the most terrible injuries. The narrative is gripping, and the reader shares something of the same sense of nervous anxiety about the outcome of what is attempted.

But the book is also open about when things don’t turn out so well. Sometimes because the odds are just too strongly stacked against the patients, sometimes because the limited resources and facilities are just not sufficient but sometimes, whether through exhaustion or plain misjudgement, he or colleagues make a mistake. Such factors can be part and parcel of clinical work in any setting but are more so in the specific circumstances in which such humanitarian work is carried out. The book is so much the better for the honesty with which the real story of clinical endeavour “in extremis” is narrated.

There are many moving parts of the book, but the most powerful stories relate to David Nott’s work in Syria, in particular in the city of Aleppo. He visited the city on two occasions, on the first, the conflict more evenly matched but by the second the forces of both the regime and of ISIS were making life for the civilian population virtually untenable.

Of all the civil conflicts I have witnessed in my lifetime the one in Syria has been one of the most troubling. The extent to which the Assad regime has been prepared to inflict unspeakable cruelty on any section of their own population has been staggering. Indeed one of the most powerful images of the story is the shared background between Nott and Assad himself, both London trained doctors whose paths had, in very different previous lives, crossed but who epitomise such radically different approaches to human life and suffering. It is a conflict, yet without resolution, where all attempts by the West have seemed to be futile and self-serving.

As well as experiencing unspeakable horrors in terms of the clinical cases he has to deal with, Nott also, at times, comes close to danger and, even death, himself. There is the occasion a group of ISIS terrorists storm his operating theatre in mid procedure or the times he has to brave hostile checkpoints on the Castello Road out of Aleppo. When I started reading the book of course the exposure of individual frontline health workers to immediate danger felt exceptional. By the time I finished it has, sadly, become an everyday event.

Nott also describes powerfully the experience of moral injury, a concept, which again has acquired a clear level of interest in the time of Coronavirus. This relates to some of the imperfect judgements he has to make, at times, when time, circumstances or resources mean he cannot take what would be the usual course of clinical action in treating a patient. On top of that he talks movingly of the dilemmas he had to face in deciding whether to treat wounded terrorists who, themselves, had been the source of suffering for others or who would go on to be so in the future if they recovered from their injuries.

There is a personal story too in the book. First there is his deep sense of Welsh identity, which, obviously, has a strong resonance for me, grounded in the experience of having a Welsh mother and growing up with his welsh speaking grandparents in Carmarthenshire. Second there is experience of meeting his wife Elly, after many years as a lonely hero, someone who has a profound ability to both love him as an individual and understand the importance of his work.

Elly has worked with him to establish a charity, the David Nott Foundation  which is working to provide training for clinicians from across the world who work in war-torn countries and other troubled environments. It is a cause well worth supporting.

This has been an inspiring book to read in times which themselves are challenging for all us. David Nott’s determination, courage, and humanity can be a source of inspiration for how we all may need to step up to the mark to help others.

Working from Home – will it ever catch on?

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Three weeks has turned us into a nation of home workers.

While I am still going into the Tavistock Clinic on an occasional basis, like the large majority of my colleagues, I am doing most of my work from home. While, in small doses, always part of my routine it has been staggering to see how easily the transition to remote working can be made, when necessity requires. Already the question is being asked about whether we should ever go back to our old ways.

With new technology and, in particular, video conferencing platforms such as Zoom, Skype or Microsoft teams (you can take you pick which think is the best) it is surprisingly easy to run an organisation remotely. We had our first online Board meeting this week and, once in our stride, it was as good a discussion as we have normally. During the Covid-19 crisis I have been holding twice weekly staff briefing sessions, attended on each occasion by more than a hundred members of staff, far more people than ever attend my normal CEO Question Time.

Across our Trust, staff are also grappling with the task of delivering clinical care and training and education through remote channels. While it’s still quite early days the response has been pretty positive. There are challenges. Remote delivery can expose the digital divide, not all our patients have access to good quality kit or a decent broadband connection. Clinicians report greater difficulty in engaging with and assessing new patients compared to supporting and offering therapy to those patients they are already familiar with.

We also need to hear patients’ side of the story. In the short term there may be any element of gratitude for still being able to receive a service without having to attend a physical location where they may be at risk of infection. While, given my history with NHS Direct, I have always been a strong believer in the appropriateness of remote care, I still think we need to gather some feedback and data from patients before we rush to conclusions about the scale of change we can make.

There a number of real potential gains from making permanent changes in how we work. The first, and for me, biggest relates to how technology can overcome distance. Remote working can eliminate countless avoidable journeys, something, which with our concerns about climate change, must be something to embrace. Journeys to access NHS care account for a very significant proportion of emissions in the UK.  Reducing them will both help save the planet  and help improve health.

Furthermore, it can also remove the hierarchies of location and give genuine equality of access, whether to care, education or information to individuals, irrespective of where they are located. I am really struck with how, at my virtual staff meetings, it is so easy to include staff from our satellite locations who are normally excluded from many normal events.

There is also a question of efficiency. We waste a lot of travelling. I have been struck by how much it is possible to fit into a virtual day at home. However, I have also been aware, as have others of quite how exhausting a day packed full of remote meetings can be. Engaging through new technology is far from relaxing. However, if we make the right judgements about what is possible, I think there are some real gains in terms of improved productivity which are possible.

There are also potential gains in relation to flexibility, and when managed appropriately, to make it easier for people to combine work with family responsibilities. I think of the times that I didn’t have with my children when they were growing up because I worked at distance.

As with all things in life this will not be a case of what we do but how we do it. There is no doubt that the experience of the pandemic will create the potential for a major shift in working practices. The big game changer is not so much the availability of technology per se (that has been building up for a while) but the face that Covid-19 has forced us en masse to change what we do. Some of the resistance which would be normally in place has been there because we have had to act through necessity and that the same rules have applied to all of us.

However, if remote working, and in particular the delivery of remote clinical care, is to gain real traction we need to evaluate experience and think carefully about how we design the systems and rules which support this model. While greater efficiency may be possible it should not be the principal rationale for action.

Finally, in redesigning work we must prioritise our fundamental characteristic as social beings. Work meets very important needs for social interaction and engagement. We must not lose sight of that and make sure it is built into our future thinking.

That affects the virtual space as much as it does the future balance between remote and face to face working. One of the interesting narratives in my organisation in this last week is how teams have been finding innovative ways, from having debriefs at the beginning and end of the day to sharing team playlists, to engage and maintain social contact while working remotely. Such things are really important. When I asked, at the end of my remote staff meeting, what we could do to improve their working there was a consistent response. More pets.

Caring for the Carers in the time of Coronavirus

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Amongst the many other things happening to respond to the impact of Covid 19 I am pleased to see a growing focus on protecting the wellbeing of staff in health and care services who will be at the front line of the crisis.

Coming from an organisation founded in the wake of the First World War and active in the Second in responding to the impact of battlefield neuroses I think there is much to learn from the history of psychological trauma in the time of war and how that has either been well or badly managed.

The BMJ published an excellent article on this topic this week by Neil Greenberg, Professor of Defence Mental Health, Simon Wessely and others. It is well worth a read and sets out the key principles which we need to design into any programme we put together to look after our workforce in this period.

The article highlights that, as well as the normal trauma of healthcare, no doubt heightened as is clear from the first hand accounts of clinicians working in this country and places such as Italy where the virus has already had a greater impact, staff are likely to experience moral injury. This term describes where staff are exposed to challenging decisions about the allocation of resources or the decisions they take about the care and support of patients which they are unprepared for and which violate their moral or ethical code. Moral injury is not itself a mental health problem but will have a significant impact on morale. Furthermore, in its wake, unsupported staff are more likely to be vulnerable to burn out and to long term mental health problems.

For me the situation requires a number of ingredients in forming our response.

First a recognition of the seriousness of this issue, given the unprecedented nature of the situation and its likely duration. This needs to be seen through the lens not just of making adequate provision for those who develop the most significant issues but as a requirement to resource a universal offer which helps to support morale and wellbeing in ways which enable staff to do the difficult jobs we will be asking them to carry out and act as a protective factor in respect of future distress.

A universal approach also needs to take account of the breadth of the health and care workforce. This is not just about happens in ICUs, however gruesome that gets. Nor is just about clinical staff. Distress and moral injury can happen in many settings. One of the really good features of the last couple of weeks has been the profile which important support functions such as IT and clinical admin have acquired as we deliver fundamentally different approaches to the model of care.

We also need to think through to different forms of distress and moral injury. Some, indeed, will relate to the challenges of supporting patients who have the virus. There will also be issues with the compromises we are forced to take in how we help, in this time, other groups of patients.

The BMJ article rightly highlights the evidence around the protective role which local management can play. This is a very strong lesson about this from the experience of both military settings and workplace wellbeing more generally. We did need, as senior leaders, to have a particular eye to how we look after that group of staff who themselves who will be vulnerable both to a period of illness with the virus but also psychological trauma and moral injury.  Indeed, difficult decisions about the allocation of scarce resources and the acceptance of “suboptimal care may be most acute at this level.

The final principle of how we need to work needs to relate to a commitment of sustaining focus and support for the duration of the pandemic and beyond. By any standards this will be a long haul. Furthermore, we know from the clinical experience of managing trauma that the worst effect can come later, when the original incident has passed and some semblance of normality returns. It is then that unprocessed trauma and feelings of guilt can be at their most toxic.

I am pleased that my Trust, working with partners in North Central London has been trying to put these principles into practice in developing a systemic approach for supporting staff across all sectors in our patch. Our approach NCL in Mind has focused on trying to provide a range of relevant material and advice which can reach across the workforce and to combine this with developing a support line to support all those groups in local organisations to try to deliver a joined up response. Finally, we are aiming to use facilitated online fora or “Connecting groups” to give staff in different settings a chance to process some of the problems and moral injuries they are facing.

There are many imponderables about the next couple of months and how the health and care system will weather the storm which is facing it. I am, however, convinced that looking after the welfare and wellbeing of our workforce, now and for the future, will be one of the most important priorities to address if we are to get through it

Interesting Times

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I wrote a blog last week about the impact of the Coronavirus crisis highlighting the unprecedented nature of the events we are going through, both in the NHS and more widely.

A week further on, events have developed with such intensity. Schools, pubs, restaurants are closed, and the NHS has been put on a definite war footing. Most of those things which were still most important at the beginning of last week have faded into the background. One objective has a universal focus, that of limiting and managing the impact of the virus and dealing with its wider impact on society.

It has been an amazing time to be a leader and it has been a week where all the usual norms of how we do business in the NHS have been stood on their head. Despite the enormity of the situation we are facing it has been inspiring and humbling, in turn, to see the way which staff and managers have come together, determined to do their best to support their colleagues and patient care. Generosity is the word which most sums up the spirit in which business has been taken forward.

As well as the natural response to a crisis of this scale it strikes me that what has happened is to unleash the underlying motivation and passion which has brought most of us into health and care in the first place. So often, in normal times, the system, often for seemingly good reasons, gets in the way. However, in the last week, considerations of finance and regulation have been waved away or at least moderated so we can get on with the job. We are mobilising services and changes to practice, which if not impossible, would normally take months if not years to deliver.

Whether this sense of euphoria and freedom will last, as the situation continues and the reality on the frontline worsens, we will have to see. Changing my sporting metaphor from last week, playing for 80 minutes is tough and will require reserves of patience and resilience which will test most of us.

I am confident that some of this new spirit will flow through to future times and we must make sure that we take the time to reflect on what is happening and capture the changes in focus and activity which are most relevant to the resilient and sustainable delivery of health and care in the future. I have argued this week, within my organisation, that its worth remembering that many of the jewels of the post war settlement, including the NHS itself, were forged in ground breaking thinking and debate which happened in the midst of the Second World War.

Even such a short time into the crisis two things, at least, stand out very clearly already.

The first relates to social care. If we have not enacted a fundamental social care settlement by the end of this Parliament, we will have failed to take a historic moment. A moment where the significance of an extensive and resilient system of social care in looking after the most vulnerable and preserving our hospital system to carry out its unique role in providing specialist medical care has become so clearly visible. A moment where the political will to create a generous and sustainable source of funding for social care may at last be possible. The early signs are encouraging with a significant level of COVID 19 funding being allocated to support social care’s response to helping discharge patients from hospital.

The second issue relates to the use of technology. I am hopeful that, very shortly, the majority of my Trust’s business, clinical, educational and administrative will be done remotely. I wouldn’t characterise the organisation as anti-technology in the past but, inevitably, things have, at times, moved slowly. There will an enormous amount to learn about how to do this well and at scale and some things will revert to being done on a face to face basis, even if they can for a while be sustained remotely. However, having taken the plunge on the back of this crisis, I am sure that there will be a platform of willing support for a fundamental shift in our approach. Having had to self-isolate, myself, this week due to my wife having symptoms I have been struck, personally, but how possible it is to shift a way of working.

Back to Coronavirus itself. There is no doubt we are reaching to a crucial point in the crisis with a noticeable rise in the level of infection and deaths. We are moving, more quickly than was initially anticipated, to the need for greater restrictions on our personal freedom of movement (I really don’t like the term lockdown). It is a strategy which seems inevitable to save lives and protect the capacity of the NHS.

At the same time the economic and social consequences of such action, as ever more keenly felt by the poor and vulnerable, of such a dramatic shift in are also emerging. Nothing brings that home, more acutely, than the isolation of my 92-year-old mother, who has dementia and who is trapped in her nursing home, cut off from the family contact which has been such a sustaining part of her life. While we need to enact the steps we need to take to save lives we also need to be thinking, just as hard, about how we mitigate the significant impact of social isolation and economic distress which could last a long time if we can not find an effective vaccine or treatment for COVID 19.

These are interesting times. So far, in health and care, it is bringing the best out of people. There is, however, a long way to go.

Keep Calm and Carry On

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I can think of few weeks in my working life like the last one, as a gathering sense of the significance of the Coronavirus outbreak rapidly brought new challenges and dramatically reordered priorities.

A strong framework of planning and preparation is rolling out across the NHS but with an understanding, at the same time, that what we are being asked to deal with is beyond the normal range of operational contingencies. We are, very much, in uncharted waters.

As one tries to get one’s head around what will be required a number of things stand out.

First, more than any of the policy drivers which have been pushing us in recent years towards integrated working, the threat of Coronavirus calls for system working and the ability for us to share knowledge and resources between organisations. That’s very much the flavour of the discussions I have seen so far.

Second the success of the response to Coronavirus in the health service will depend on our ability, as far as possible, to support staff and maintain morale. We will, inevitably, be asking staff to do some tough things over the next couple of months, and, more importantly, things which are out of the normal run of clinical practice. Some of the stories coming out of Italy, where the immediate pressure on Intensive Care Units has been intense, highlight what happen.

We need to provide staff with the right framework in which they can take difficult decisions about clinical cases and priorities when what might, otherwise be optimal, is not possible. We need to develop systems to support staff facing the trauma of levels and types of distress which are not routine.

We also need to acknowledge that staff will have anxiety about their own health and that of their families. A decision about the closure of schools, which may, at some stage, be necessary will have a profound impact on the NHS workforce, given its profile.

The third thing to recognise is that this will be, as the phrase goes, a marathon not a sprint. Whatever measures we take will need to be sustained over a relatively long period. There will be difficult choices to make about the trade off between our response to Coronavirus and other priorities such as the urgent requirement to develop mental health services.

In a complex system such as the NHS, the next period will need a particular type of leadership. Leaders will need to be clear about what they focus on and make sure that what they promise happens. They will need to be visible and available for staff.

However, this is not the time for endless discussion or grandstanding. While focused consideration and challenge are always necessary, a cacophonous and endless debate about strategy is not helpful. Some of this weekend’s discussion in the media and social media has been veering into that territory.

What happens outside the NHS will be equally important. While there is inevitably an immediate focus on limiting the impact of the virus in terms of loss of life the pandemic will have much wider consequences, as will, inevitably, the measures we take to limit its spread.

The economic results of Coronavirus are bound to be very significant. As well as the general threat of a recession I would be particularly concerned about small and medium sized enterprises which might be particularly badly affected and who have little capacity to weather a sharp economic shock of this nature. Government must urgently address action to protect, and just as importantly, reassure such businesses which remain the lifeblood and heart of our economy.

Most significantly I am deeply concerned about issues of loneliness. There needs to be such a careful consideration of the balance between measures to protect physical health in vulnerable groups and the psychological damage which is caused by exacerbating social isolation amongst groups for whom lack of social contact is already an acute aspect of distress. In personal context I think of my 92-year-old Mum with dementia for whom family visits to her nursing home are a very important part of her quality of life. There are no easy choices but let’s make sure decisions are taken through a broader lens that just that of physical health.

Our public discourse over the last couple of years has made a lot of reference to the experience of the Second War World and a collective sense of “our finest hour”. As with every narrative there are two versions. One of the most fascinating conversations I ever heard my parents have was around contrasting memories of that period. For my father the War had been a time of community solidarity and heroics as he joined others on fire watch on the roof of the local school. For my mother, as a teenage girl, she he had seen the petty side of wartime behaviour with sharp elbowed attempts to work the rationing system for individual benefit. It is interesting to see both those behaviours playing out, on the one hand, in the stockpiling of toilet roll and pasta and on the other lots of examples of the schemes I have seen on social media to support isolated neighbours.

There are aspects of the British character which are well suited to managing times of difficulty. Keeping a sense of humour, whatever happens, will certainly be one. The other will be a sense of a perspective and the ability as the wartime poster said to keep calm and carry on.

As my Whimsy takes me – in praise of the detective fiction of Dorothy L Sayers

Roy Ridley

The Lord Peter Wimsey novels of Dorothy L Sayers were one of my first literary crushes as teenager. In the last year I have made a point of returning to them, enjoying rereading those which I had first read more than 40 years ago and discovering, for the first time, one or two new ones. I also got the chance to read Barbara Reynolds lovely biography of the author – Dorothy L Sayers: Her Life and Soul which, in the best tradition of good biographies, describes with sympathy and insight a remarkable and engaging woman.

Returning to one’s past can be a dangerous pastime but I found, for the most part, I was still as enchanted, in my fifties, by the books, the characters and the energy and quality of Sayers’ writing as I had been in teens. It is true some of the context had changed. When I read them for the first time in the 1970s, I knew much less about the world but in other ways I felt closer to the stories whose characters and author were contemporaries of my grandparents and their generation, some of whom were then still alive. Rereading them in 2018, that world seems more distant and I was struck by some of the descriptions and attitudes, including, a very clearly class driven view of society and even some occasional casual racism, which grated in today’s world.

Detective fiction is an interesting genre. In English, the origins trace back to the work of Edgar Allen Poe, later to be developed by Arthur Conan Doyle with his stories of Sherlock Holmes. Sayers is an undoubted master of the form combining well-constructed mysteries (her own view was that the construction of a good detective novel had to start with the crime, how it was carried out and how it could be discovered), with attractive and fascinating characters and powerful insights into human character. The writing is excellent, clear, energetic and hardly ever loses the reader.

At the centre of the novels is the aristocratic sleuth Lord Peter Wimsey, intelligent and sensitive, war hero (and victim of shell shock) musician and book collector who turns to detection as an occupation and purpose in life. In his powers of observation and deduction he has some resemblance to other great detectives such as Sherlock and Poirot but Wimsey succeeds in being much more than just a detective, most clearly in the description of his drawn out, but eventually successful, romance with Harriet Vane, the writer of detective fictions whom in one of the novels, Strong Poison, he manages to save from the gallows.

Drawing from Barbara Reynold’s biography, it is clear from Sayer’s own testimony that the character of Wimsey was constructed drawing from various figures she had known. In particular Roy Ridley, whose picture is at the top of this blog and who became Chaplain of Balliol, Wimsey’s Oxford college (and my own – it was my best line at my interview that I had chosen Balliol to apply to because Lord Peter Wimsey had been there) who provided the physical inspiration for the character.

Wimsey is assisted in his work by his valet Mervyn Bunter. Bunter had been Lord Peter’s batman in the War and his understanding of his employer’s mental states has been crucial to him emerging from the dark days of shell shock. Bunter is brilliantly well organised, and Sayers is quite happy to allow the similarities to be drawn with another contemporary valet of fiction, Reginald Jeeves.

As well as ingenious crimes and clever deduction the novels have some wonderful backdrops: Murder must Advertise, the first one I ever read, is set in an advertising agency, drawing on Sayer’s own rather successful experience working in the industry; Five Red Herrings is located in the fishing and painting communities of Kirkcudbrightshire and Gaudy Night which is set amongst the intrigues of a woman’s college in Oxford.

Plausibility, the greatest skill of a writer of fiction, is always present in Sayer’s writing, reflecting either the worlds, such as advertising, she already was familiar with or others such as campanology in The Nine Tailors which she scrupulously researched. The Nine Tailors, set in the fenlands in which Sayers grew up, is my favourite of all the Wimsey novels. It combines a great plot with a wonderful sense of atmosphere and place.

One of the things which good detective fiction elicits from its readers is a powerful desire to believe that the story described, and the characters portrayed are real. That’s true of other fiction too but maybe there is something about the sense of anxiety that detective novels generate which heightens that belief in realism to a greater extent. It was certainly how I felt about Wimsey when I referred to him in my University interview.

Dorothy Sayers’ career spanned much more than detective fiction. She was in the first cohort of women to graduate formally at Oxford University, she was a talented linguist who produced a brilliant translation of Dante’s Divine Comedy (still available today). She also had, appropriately as a Vicar’s daughter, a career as a religious writer who was keen, as she did in her radio play The Man who would be King, to present religious issues in a challenging and accessible manner with none of the characters speaking “in Bible”.

Dorothy Sayers was a shining example of a generation of women, who in the aftermath of the First World War, broke through into public life. For me as teenager in the 1970s she was a figure who helped inculcate in me a deep-felt respect for women as intellectual and social equals of men. As well as many hours of literary enjoyment I am very grateful for that legacy.