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Technology – can it be the magic bullet for the NHS?

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It seems clear that Matt Hancock has chosen technology as the big idea to mark his tenure as Secretary of State for Health and Social Care. There are good reasons for doing so. There is no doubt about the transformatory nature of modern technology and the health and care sector has been slow in adopting its potential.

Twenty years ago, I was very privileged to have a job leading the implementation of NHS Direct, a service which was a genuine exemplar in the use of technology in the delivery of healthcare. While technology has developed enormously since then, many of the fundamental challenges around the effective use of technology, remain, in my book, the same. I wanted to use this blog to reflect on some of those issues.

Technology can have enormous benefits in improving the quality and cost effectiveness of healthcare. Four things stand out.

First good technology can improve the safety of healthcare by providing clinicians with point of contact information about a patient’s individual history and condition and the best evidence on how to treat it. In addition, when things do go wrong, it can provide a much stronger basis for determining what happened.

Second technology can promote access and facilitate the best use of clinical time, in particular of specialist clinical staff, by reducing the need for travel time and of, some groups of patients, reducing some of the barriers to accessing care.

Third digital applications open the potential to involve patients proactively in their care by supporting self-monitoring and self-care and facilitating peer support. As various approaches in mental health have demonstrated intelligent remote monitoring can help make the best use of clinical capacity, targeting resources on those in immediate need rather than tying up time in routine appointments.

Finally, there is enormous potential in the data generated through the use of technology to help improve care, better target resources and support research into future treatments.

While developments in Artificial Intelligence have perhaps extended the range of possibilities the basic parameters of what technology can offer are very familiar from what I encountered when working on NHS Direct. The bigger question is not what is on offer but what are the challenges in realising those benefits and where are the potential risks in how this is done.

There are again four key questions.

To start with how we are sure that technology is addressing the current need for healthcare rather than just stimulating an additional level of demand? This was always a dilemma for NHS Direct and the challenge is all the more acute in times of more straitened resource. Technology can make it easy to improve access but that will be counterproductive if it generates additional downstream demand which the system is not resourced to deliver. An exception might be if we can target interventions on areas where late identification of symptoms has a negative impact on patient outcomes or costs.

The second question relates to the implications for staff of technologically driven change to their working practices and lives. As anyone who has been engaged in a technology project knows, the technology is the easy part, it’s the people bits where all the real challenges rest. If we are serious about technology driven change we need to invest heavily in staff training and in the effective redesign of care pathways in ways which seamlessly incorporate technology. In doing so we need to be open the very real anxieties which staff have about the impact of technology on their jobs, in particular in relation to issues of control, and, just as importantly, their professional worth. I was always struck by the extent to which GPs felt threatened by the introduction of a nurse led service in NHS Direct.

A third consideration must be the issue of digital inequalities. This can, at times, be overplayed and for some groups, for instance young people, digital applications can offer better ways of connecting with populations the NHS struggles to reach through old fashioned means. (It staggers me, for instance, in 2018 that the NHS still uses snail mail as its predominant means of communication with its younger patients). The trap to be avoided is to take a one size fits all to digital development which sees the world sole through the lens of the middle aged, middle class smart phone user. As a universal service the NHS also needs to keep open a variety of channels and approach based on “clicks and mortar” must be on offer.

The final question relates to where to ownership of digital developments best sits. As with all structural issues the NHS has oscillated between centralism and localism. The National Programme for IT has cast a long shadow and while to drive a certain measure of progress in digitising the NHS did so at the expense of disempowering local organisations, and front-line clinicians. Perhaps there is never a totally right answer but perhaps STPs or ICSs provide a level where, for some issues, you can get the best balance between ownership which is so crucial to service transformation and economies of scale in relation both to cost, but just as importantly the management of resources and contracts.

It is one of those adages that we always overestimate how different the world might look in two years’ time but consistently underestimate the level of change ten years might bring. The current Secretary of State might not be around in ten years’ time but sure as anything technology should be central to the development of health and care.

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In praise of Uncles

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This is a more personal blog than usual, prompted as it is by the fact that today, 23rd August, marks the 20th anniversary of the death my favourite Uncle, a lovely man who made a profound impact on my interests and development. As well as a personal tribute to one Uncle it is a chance to celebrate, more generally, the contribution of those significant individuals who, whether family members or others, can make such a difference to how we turn out.

My Uncle John, my mother’s older brother, was a very special man. He was the first member of our family to go to University, he was a war hero who survived being blown up in tank in Italy, he was cultured and well-travelled and a wonderful raconteur and conversationalist, a talented artist and amateur actor. He had that gift of brightening up any room he walked in and making fun and adventure out of the most mundane of situations. He was a man of principle who encouraged me to take an interest in public affairs. Despite all of that I remember him most as man who always had the time to take in an interest in what I and my brothers were doing.

We were lucky that I and my brothers were quite a lot younger than his children and that, as result, he and my aunt had the time to see us quite regularly. I have a special memory of when they joined us at Christmas time. He would contrive to create a wonderful set of Christmas party games, well beyond our own, somewhat Puritan traditions, which transformed the occasion. He is a man whom I have missed deeply ever since his death.

I have much to thank other significant individuals in my life. My grandparents, especially my grandmother, who I was able to spend so much time with as a child. My Welsh aunt who opened her home, each summer, to give our family a holiday and who helped cement my lifelong love of the land of my fathers; a number of teachers who took a special interest in my development and who encouraged me to expand my interests and to explore horizons beyond what was common place in my family; early bosses who backed my ability and gave me the chance to progress and to take opportunities which have been crucial to the success of my career.

While nothing can take away from the role of parents in my upbringing I have been immensely lucky to have access to that wider network of adults who have been able to offer me perspectives and opportunities which it was not in my parents’ gift to provide.

This story has a number of wider lessons. First it stresses for me the value of intergenerational relations and how much we, as individuals, can always learn and benefit from those with different life experiences than our own. We need to guard against the divisions in society which seem, increasingly, to be isolating us from those who are different from us or who hold different views. Some of this can play out across the generations and we need to guard against that. I have a number of good Indian friends and I have always liked the way they address as “uncle” individuals of an older generation with whom they have a close connection.

My second point relates to those without access to the same opportunities as I had. For those who have lost parents through death or separation or who in other ways have had traumatic childhoods, special individuals can be particularly important in helping someone overcome their difficulties. Some people have scarcely ever felt the benefit of someone taking an interest in their story or their development. I see every day in my work in mental health the crucial value of sustained therapeutic relationships in supporting recovery and the roles of peer workers and mentors are also enormously important in supporting individuals who have experienced difficulty. We need to think about this carefully in the way we design and invest in public services.

My third point relates to our own behaviour and what we do, beyond our formal responsibilities, to take an interest in the affairs of others. It can, of course, be very easy to be too busy to take the time to do so but the difference that is made by learning someone’s name and story and spending time, formally or informally, supporting and encouraging them on their journey is incalculable. After nearly 12 years as a Chief Executive I have realised that it is the most significant thing I do.

Twenty years ago, I raised a glass, with others, to the memory of a very special man. I do so again tonight, grateful for the contribution he made to my life and mindful of the example he set about in taking an interest in the lives of others.

Reflections from a small land

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Summer holidays are always a good time for reflection. This year we’ve been to Lauterbrunnen in Switzerland, in the heart of the Alps. JRR Tolkien came there in 1911 and this narrow mountain girt valley with its 72 waterfalls it is thought to provide the inspiration for Rivendell, the home of the Elves in the Hobbit and Lord of the Rings.
Our trip has prompted a number of thoughts both about Switzerland and its place in the modern world and about some wider issues.

This was my first extended visit to Switzerland although I have made a few shorter visits in the past. In some ways it was quite familiar. I remember Switzerland being quite in vogue in my childhood with the, then novel, excitements of eating “Swiss style breakfast” cereals and watching Swiss Family Robinson on the television. As ever there is more to Switzerland than that and now, in the light of Brexit, it strikes me there is some considerable value in taking an interest in its affairs as country which sits, in the heart of Europe, but is not a member of the EU.

Reinforced by its geography this not one country but many. This is a federal country in the full sense of the word, “Confoederatio Helvetica” being the Latin name which is reflected in the “CH” stickers on Swiss cars. There are four national languages: German, French, Italian and Romansh and, under the Swiss constitution, the federal Government is an explicit sharing of sovereignty by the 26 cantons rather than a top down imposition of national authority.

National Government is shared through a seven-person National Council, elected for a four-year term, across the political spectrum and the figure of the State President, whom we saw give his traditional address on 1st August, Swiss National Day, rather like the Queen on Christmas Day, is elected by other members of the Council on a one-year basis. The President is primus inter pares with other members of the Council and has no additional power. Swiss politics seems to eschew any focus on personality, a health antidote to the dramas playing out in the Uk while we were away.

All across Switzerland the emblems of cantons and local communities (Gemeinde) were as prominent as that of Switzerland. Managing diversity of interest and working through consensus, not diktat, seems to be hard wired into the Swiss political psyche. The Swiss tradition of direct democracy also has major influence on the shape of Swiss politics.

The other thing which distinguishes public affairs in Switzerland is the country’s deep-seated commitment to neutrality. It has not been at war internationally since 1815 and the principle of neutrality still is at the heart of Swiss foreign policy. As was clear from some of the debate we saw in the Swiss media, that principle comes in two forms, an open and outward looking form which looks for the country playing an active role in international affairs, for instance by taking a permanent seat on the UN Security Council, or one which envisages neutrality being more insular and isolationist in its character.

Both these issues, how we order the relationships within the different parts of the UK and what are the fundamental principles which drive our future relationship with the rest of the world seem to be absolutely central to how we work through the dilemmas around Brexit. It was also salutary to note, that despite its strong sense of independence and the reluctance of the Swiss public to contemplate joining the EU, how central the relationship with the EU is in defining Switzerland’s economic and regulatory policies.

Time in the mountains promoted two other reflections. We enjoyed, like the rest of Europe, two weeks of generally excellent weather but the high temperatures also reminded me of the significance of global warming. Nowhere was this more noticeable than in the shrinking of the Alpine glaciers. There is a lot to worry about in the world at present, but it feels to me also a real risk that, amidst other issues, we fail to take seriously enough the biggest threat to our world. The sight of the mountain rivers in flood with the melted ice of the glaciers was a timely reminder of this issue.

My final reflection was a more serene one. The landscape we were staying and walking in was phenomenally beautiful, with wonderful vistas of some of the most significant Alpine mountains such as the Eiger and the Jungfrau. One of the reasons I have always loved the mountains is the way in which both in scale and timelessness they dwarf our human ambitions and anxieties. Close to where we staying were the spectacular Staumbach falls. At the bottom of the falls there was an inscription of some verses of a poem by Goethe who had visited the valley at the end of the 18th century. They read:

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“The souls men, you are like the water, the fate of men, you are like the wind”

Perspective is very important in life. These words and the sensational beauty of the place offered a sobering perspective for my own petty concerns and anxieties which I will try to take with me as I return to the wear and tear of daily life.

The will of the people – remember Arginusae

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This has been a profoundly depressing week in politics. The division in British society over the consequences of the Brexit vote continue and there appears to be a frightening willingness to put narrow ideological goals above any wider view of the national interest. Usually I have a strong feeling for the British ability to muddle though but, over Brexit, I beginning to wonder.

Readers of this blog will know the value I attach to looking at what history has to teach us about the events of the present. On this occasion I am drawn to thinking about one of the most traumatic episodes in the history of early Athenian democracy, the vote to condemn to death the victorious generals at the Battle of Arginusae.

This happened at the end of the fifth century, in the last years of the Peloponnesian War between Athens and Sparta. After the disastrous expedition to Sicily, Athens had been on the backfoot in the conflict with Sparta. They had flirted with Alcibiades as a potential saviour, but he had gone into exile in Persia. Slowly, they had made a come back and in a naval battle off the cost of what is know Turkey had inflicted a significant defeat at the Battle of Arginusae.

There had been, however, been a sting in the tail. A storm which had blown up at the end of the battle had prevented a pursuit of the defeated Spartans but, more significantly, it had prevented the rescue of Athenian sailors whose ships at been sunk and who were left stranded in the water. When the generals in charge of the action returned to Athens, instead of facing a heroes’ welcome, they were confronted with public anger at the loss of Athenian life. In anticipation, two of the generals decided not to return to Athens but went into self-imposed exile.

The issue was taken to a special meeting of the Assembly, the ultimate body of Athenian democracy in which every male, freeborn Athenian citizen was entitled to take part. The president of the Assembly was chosen, each day, by lot and, as it happens, the president for this momentous day happened to be the philosopher Socrates. The Assembly debated an extraordinary proposal for all the Generals to be tried together by the Assembly itself. If found guilty, the penalty would be death.

The debate raged fiercely between emotion, fuelled by the testimony of a survivor from Arginusae who had survived clinging onto a wooden flour tub and rationality as others tried to point out the genuine difficulty of rescuing the men given the weather conditions. Socrates, as President and himself to fall foul in later years of the anger of the populace, tried to keep the debate in order and to resist the call to put the proposal to put the Generals on trial to the vote. In the end, thinking at last that a rational outcome would prevail, he allowed the vote to proceed. The vote went against him and subsequently the generals, who included the son of Pericles, the most famous statesman of Athenian democracy, were sentenced to death.

Remorse came quickly, and the populace turned on those political leaders who had led them onto to take this regrettable decision. It was, however, too late. A year later the Athenians were defeated at the battle of the Aegispotami. Unable to defend their grain supply from the Black Sea, the Athenians were brought to a final and humiliating defeat. Although it later recovered one of the long-term consequences of Arginusae was the reluctance of people of talent to serve in position of public responsibility, knowing that they, like the generals at Arginusae could be victim to the whims of public anger.

There are many features of these dramatic events form the past which resonate with current events. The triumph of emotion over rationality, the contempt for traditional politicians and people in roles of leadership, the ignoring of the views of experts, the manipulation of procedure, so central, in all times, to the operation of democracy.

With the advent of social media modern democracy has moved closer to the paradigm of its ancient predecessor with more riding on the moment and ordinary citizens closer to the action. Democracy, no less than other forms of Government, has always been vulnerable to the manipulation of the anxieties and other emotions of the populace. Those feelings have to be acknowledged but they should never be the basis for rationale decision making about complex issues of national strategy.

Had Socrates prevailed and there had been a moment for reflection it is possible that the Assembly would have repented of their anger against the generals. In our current national debates about Brexit there is a crucial need for such a moment of reflection.

The Open Society

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One of the most powerful things I read when I was studying history at University was the philosopher Karl Popper’s “The Open Society and its Enemies.” Written at the end of the Second World War it made the argument, starting with Plato’s Republic, against the closed ideologies of totalitarianism. Popper’s argument is that in trying to order society and insulate it from external change, totalitarian regimes inevitably fall into abuse: suppressing the truth and oppressing their citizens. Manipulation of the historical narrative is one of their principal tools.

I read this work through the lens of the mid 1980s and the latter days of the Soviet hegemony. Popper’s argument appeared a self-evident truth as the communist regimes of Eastern Europe staggered towards their eventual decline. Recent events have made me think, once more, about these arguments as, again, liberal democracy appears to be under threat, a narrow nationalism is on the rise and the principles of the open society challenged and subject to question.

At the heart of the debate is our attitude to the movement of ideas and of people and how we embrace change in our world. Whether, as default position, we are open to change and new developments or whether we wish to look back and lock down the world, in some sense, in a paradigm of a personal, sectional or national past.

All of this appears to be playing out in a large way in current events whether over Brexit, the rise of Donald Trump or the emergence of different shades of nationalist and popularist politics across Europe and elsewhere. The impact of globalisation, the shift of economic and political power from the West, the scale of migration and economic pressure and public austerity all seem to be fuelling a shift against the values of liberal democracy and towards a more inward facing creed of nationalism. History never repeats itself exactly but the parallels with the 1930s are far too close for comfort.

My experience and study of history would teach me to side with Popper. That is that human development and progress has usually been linked to open societies and the free interchange of ideas of people and the creative energy that this unleashes. Nowhere epitomises this more than ancient Athens, the single most brilliant example of human development, in the Western world at least, which in a period of less than 200 years created the building blocks of western intellectual, political and cultural activity and whose legacy can be profoundly felt today.

In saying this it is important not to discount the anxieties which have fuelled the emergence of popularist and nationalist feelings nor is it necessarily wrong to value and want to cherish the past or defend traditional values or activities. The 20th century might have succeeded in condemning the Welsh language and the cultural traditions it embodies to the scrap heap of history. It has taken a significant act of national will to resist that secular trend and to preserve a crucial part of the DNA of the Welsh nation and people. Many people can very legitimately see change as a threat to aspects of life they value, and which have constituted an important part of their own identity.

I think in our own times three factors exacerbate the tension between the new and the old. The first is the ever-accelerating pace of technological and social change and, now, the increasing level of interaction between them. The Internet as mass phenomenon is no older than my children and there is every possibility that the next generation of technological change around robotics and Artificial Intelligence will happen even more quickly. This puts an enormous strain on our powers of adaption.

The second is the shifting balance of generations in our society with the growing numbers of older people and the declining proportion of younger people in society. In 2020 it is estimated there will be, for the first time in history, a greater number of people aged 65 and above than under 5. While there have always been tensions between younger and older generations these are made sharper by the change in the profile of society.

Finally, there is the sense that the hegemony of the west, as we have known it, and the sense of privilege which has gone with that is coming to an end. This creates particular issues and the politics of decline at a time when overall resources are challenged are never easy to manage.

The quality which, for me, is most important, in managing the tensions of these times, is tolerance. In supporting an open society, it is crucial we do so in a way which is respectful of the past and is understanding of those who are left behind by change. While we must always call out hatred and discrimination towards others we must do so in a way which is, in its own turn, measured and free of hatred and intolerance. In an increasingly divided world that is not an easy ask but is an essential if we are to avoid a return to some of the horrors of totalitarianism which Karl Popper was motivated to write about in 1945.

 

The kindness of strangers

 

 

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As some of you will know from my posts on Twitter my mother-in-law, who has been developing dementia, went missing on Thursday night. Fortunately, she was alright but, in the hours, until we discovered that on Friday morning, it was a deeply anxious time for my wife and I and for the rest of her family.

One of the compensations was receiving a torrent of messages of concern, advice and best wishes on Twitter after I had posted her picture on Thursday evening. Some of these were from friends and people I knew, some were from total strangers. They were a great source of comfort and reminded me, once again, of how much decency and kindness there is in the world. From the news and some corners of social media it is n’t always possible to get that same message.

Having grown up with a disabled brother, the kindness of strangers has always been something I have been aware of. Ironically, blindness is a very visible disability and over the years I have witnessed countless acts of kindness towards him. Even in London, with its all rush and bustle, I am always struck by how readily people will give up a seat on the Underground for him.

Such acts of kindness go much wider. Just before I left Rethink Mental Illness I had the privilege of being involved in the events surrounding “Find Mike”. The charity worked with the campaigner and expert by experience, Jonny Benjamin to try find the person who, several years previously, had helped him when he had been on Waterloo Bridge about to attempt suicide. Jonny didn’t know his name but had a recollection he was called Mike. After a week or so the person was found, not called Mike at all, and Jonny and Neil’s story has been rightly celebrated ever since.

One of things that struck me in hearing about what had happened to find the real “Mike” was how many people had come forward. At first, this seemed somewhat disturbing, was there no limit that people would go to for a few moments of celebrity. In reality, it reflected that this was a relatively common situation and that were many “strangers on the bridge” whose intervention made the crucial difference when someone was thinking of taking their own life. On Thursday night the police told me that in cases of missing people, especially older people with dementia, it is usually ordinary people in the street, noticing someone who is distressed, who ensure that missing people are found.

In suicide prevention, the role of ordinary people, whether strangers or wider family and friends, has been recognised. There is an excellent resource which has been developed by the Zero Suicide Alliance and Relias which is designed to help give ordinary people the confidence to support someone who is in distress and maybe thinking of attempting suicide.

Ordinary people of course can also be experts. On Thursday night, as well as messages of concern and best wishes, there was some powerful good advice from those who had been in the same position, both on what was best to do and, just as importantly, how to cope psychologically with the anxiety of the situation.

As we battle to work out, in a time of limited resources, how best we can meet the level of need in society, it is crucial that work out new approaches to make the best use of the role of ordinary people, communities and experts by experience. This needs to be a partnership, not an abrogation of responsibility by the state. There were some positive aspects in the idea of Big Society but it’s juxtaposition with massive cuts in public services negated these and associated the brand with a cynical attempt to cover for the withdrawal of state support.

We’re not always very good, in statutory services, at establishing and nurturing these partnerships. We get too absorbed in our own system and its pressures to look outside and, at times, we can see such initiatives as threatening to our professional identity and worth. Yet as individuals, organisations and systems we desperately need to find effective strategies to harness this dispersed community capital to provide support to individuals in need. Volunteering and the voluntary sector has an enormous role to play in this but the same austerity which has challenged public services has also reduced its resources and capacity.

It is worth remembering that this is not a level playing field. Some individuals and groups will always be more of the subject of acts of kindness and others, whether for reasons of stigma, fear or prejudice, more likely to be shunned. The journey which mental health has gone though in the last 10 years, has, no doubt, impacted positively on the willingness of people to interact and support someone in obvious mental distress.  Other groups still have that more negative experience.

But the biggest challenge is to ourselves. Whether or not you are religious, the story of the Good Samaritan remains one of the most special parts of the Christian tradition. We can all be too busy, too self-important, too frightened  not to stop to help someone in distress but when we do, we do something very special.

 

The frank acceptance of all experience

 

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Last Saturday I went to see the production of Oscar Wilde’s “An Ideal Husband”, currently playing at the Vaudeville Theatre. An excellent cast, led by father and son, Edmund and Freddie Fox and the timeless Susan Hampshire, did full justice to Wilde’s unique combination of wit and pathos. It was a welcome reminder of how much I have always enjoyed his work.

Wilde remains a very accessible figure for a modern audience and, while, in one way, firmly set in his own era, he also manages to speak very clearly to our own. Next to Shakespeare he is one of those writers whose best lines are instantly recognisable and whose wit has a timeless quality. While less well known than “The Importance of Being Earnest”, “An Ideal Husband”, a story of political corruption and blackmail and the eventual triumph of friendship and love, is an excellent play.

It is all the more poignant, as a piece of theatre, knowing that it was first performed when Wilde was on the edge of his own disgrace and eventual imprisonment. It is hard not to sense the feeling of anxiety in Wilde’s authorial voice. His characters speak of their fear of public humiliation and disgrace and the emotional power and genuine pathos of their words is reinforced by what we now know, with hindsight, of Wilde’s predicament.

In part we revere Wilde for his wit, in part as man who became a victim of prejudice and hypocrisy on account of his sexuality. Personally, I admire Wilde for both of these things but, more than anything, I admire him for his love of beauty, his humanity, and his non-judgemental acceptance of his own fate.

Born in Dublin in 1854, the son of a successful Anglo-Irish family, his father Sir William Wilde was an ophthalmic surgeon. After first attending Trinity College Dublin, Wilde came to study in Oxford in the 1870s and later established himself as part of the English aesthetic and intellectual scene. A man who could literally live of his wit, famously telling the American immigration authorities on a trip to America in the early 1880s “I have nothing to declare except my genius, there is no doubt he would have thrived in our own age as a darling of chat shows and television game shows.

Despite this, during the 1880, Wilde struggled to establish himself as a serious intellectual figure. He was versatile in a number of artistic forms, but it was, as a playwright, in the 1890s that he really made his name and it is through these plays which he is largely remembered today.

Wilde was much idolised by society but he also made enemies, none worse than the Marquess of Queensberry, the father of Wilde’s lover Lord Alfred Douglas. With relentless hatred and prejudice, fuelled, in part, by his pathological relationship with his own son, he pursued Wilde to his eventual conviction for “gross indecency”. In a fall from grace of epic proportions, Wilde turned overnight from the society darling to a common convict sentenced to two years hard labour.

Though Wilde’s charm and wit remain a source of delight it is in the Wilde of the years of disgrace that I find the most to admire, captured in his two final works, “The Ballad of Reading Goal” and “De Profundis”, both works of great beauty but written in a very different key from what went before.

In the “Ballad of Reading Gaol” Wilde gives a profound and moving account of the horror and pointlessness of prison, made all the more poignant because its base is not self-pity but, rather, a deep sense of empathy for his fellow prisoners.

In De Profundis, the subject of the very first of my blogs, Wilde makes a reckoning of what has happened to him. In doing so, he recognises not only the horror of what has happened to him, but also, this own role, in those events. “I turned the good things of my life to evil”. Most beautifully it acknowledges his gratitude to those, such as the man who greeted him with respect when he was standing outside the Court of Bankruptcy in his prison garb, who were prepared to show kindness to him in his darkest hour.

One of my favourite pieces of music is Tchaikovsky’s Pathetique Symphony. It contains a gripping shift of mood between the third and last movements which resounds with an enormous sense of sadness. It is a piece of the same era and days after its first performance Tchaikovsky, himself a troubled man, was dead. There is a striking resemblance to the mood of Wilde’s last works.

There is a line in De Profundis where Wilde talks of the humility as the “frank acceptance of all experience. It is a deeply moving definition which I have often thought about. Wilde was a man who experienced the heights and depths of the human condition and was in the end, capable of looking both in the eye. It is that for which I most love him.