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Caring for the carers

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I had the great privilege on Thursday of chairing an excellent conference on staff stress and resilience in healthcare. It marked the launch of Workforce Stress and the Supportive Organisation , a framework which the Tavistock and Portman has developed for Health Education England to provide the basis for organisations to take a systemic approach to improving the mental health and wellbeing of their staff.

This is topic which I am very pleased to see getting much greater focus in the NHS, but it remains one where, compared to many other sectors in the economy, we remain a long way behind. It was salutary hearing Paul Litchfield, the former Medical Director of BT describing the steps a global multi-national had taken decades ago to address these issues. A number of things he suggested, such as a “passport” for staff who have experienced mental health problems, could easily be transferable to the NHS.

Like other good conferences the day was a mixture of good presentations and workshops and important conversations with those attending the event. I came away with some clear messages, many reinforcing what I have felt for a while, others new.

The case for action in improving wellbeing is driven in part by data and economics. At a time of staff shortages, we cannot afford to be losing staff in the way we are at present, with an increasing number citing well-life balance as the reason for leaving. The 2017 Farmer/Stevenson calculated that there was a cost in the healthcare sector of poor mental health of £2000 per employee per year, one of the highest in any sector of the economy.

Furthermore, thanks to the work of Michael West we know that there is a direct link between staff wellbeing and engagement and good patient experience and outcomes, including patient safety. In some ways it’s not surprising. Those who are well looked after have, by definition, more to give to those they are looking after.

One of the best parts of the event was a focus on lived experience. We were lucky to have a presentation from Adam Kay, author of the bestselling “This is going to hurt” on the reasons which led to him to leave medicine. Others at the conference shared stories of the realities of clinical work and what makes it bearable and, at times, unbearable. I was particularly struck by one clinician from a busy A&E describing the impact of high workload, constant turnover of staff, an over “macho” culture and the distress of some of the cases he saw in his daily practice on his wellbeing.

In Adam Kay’s case the availability of an optional break or a supernumerary shift after a particularly traumatic case might have been enough to keep him in healthcare. Across the NHS there are hundreds or thousands of such stories. We need to hear them much more loudly than we are doing at present. It is always possible to ignore or deny statistics. It much harder to run away from the messages of lived experience.
As the day also highlighted there are things, we can do to address this issue and improve staff wellbeing.

The first was about the importance of good line management. Stress, anxiety and other problems around mental health and wellbeing are best managed and contained by immediate managers. A bad line manager is the definition of hell, a good one the crucial difference between someone being able to cope or not.

There is interesting evidence from the military that the wellbeing of soldiers correlates closely to the quality of local leadership. While there are many good managers in the NHS we have not, collectively, invested as much in developing the skills of local leaders as we should.

The second is the crucial need to recognise the traumatic nature of clinical work and build in, as right, the opportunities for staff to have access to some kind of reflective practice. There are a range of approaches which have a proven track record: Schwartz Rounds; Balint Group, work discussion groups. All of them have a focus on allowing staff to confront the difficult issues they have encountered in their working lives and feel supported in doing so. Such processes should not only be encouraged, they should be factored in as a fundamental part of our financial modelling and concepts of productivity in healthcare.

The third area is the need to take a systemic approach and not focus on random initiatives. At the heart of this is the idea of the organisation taking responsibility for wellbeing rather assuming pressures can be absorbed by strengthening staff resilience. There was a brilliant quote at the conference form Health Education England’s, Simon Gregory which resonated with many when I shared it later on social media “You can’t yoga your way out of a toxic work environment.” It sums up the need for us to tackle the fundamental issues creating those toxic environments. Our Framework provides one approach to doing so.

My final message is the need for leadership. As the leaders of the NHS we must accept the moral responsibility we have for the wellbeing of over million people. We need to make this a focus for what Boards are interested in and what they are held to account for. We need to call out and address some of the unacceptable conditions we expect our staff to work in. We have to prioritise some of these issues over shorter-term gains in productivity and performance recognising that the wellbeing of staff now, and in the future, is fundamental to the long term sustainability of all we value about health and care.

Now that would be boasting – the music of JS Bach

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In the 1970s the scientist Carl Sagan chaired a panel to select the distinctive sounds of human life which could be sent into deep space on the Voyager 1 spacecraft. In response, the eminent biologist Lewis Thomas proposed including the complete works of Johann Sebastian Bach with the proviso that “that would be boasting”.

For a long time, Bach has been my favourite musician in any genre. The story is a lovely way for me of capturing his phenomenal and transcendent genius. In this blog I wanted to share my own appreciation of that genius and of some of the very special music he left.

I have, also, in recent years had the chance to read a bit more about Bach’s life and times. We do not know too much about his life, less than for any other major composer, but what we do know, is an interesting addition to our understanding of what motivated him in his music making.

While in no way diminishing his individual genius, it was fascinating to learn how much of a musical dynasty Bach came from. The Nekrolog, a work published after his death and including an obituary written, in part, by his son CPE Bach, traces the dynasty back to the 16th Century figure of Veit Bach a miller and musician. In total there were 50 members of the family actively involved over a couple of centuries in professional music making. Family appears to have mattered a lot to Bach and family influences were part of the rich musical tradition he grew up in.

The second distinctive feature is his deep Lutheran faith, visible most clearly in his choral music but very central to who he was as a man and as a composer. It is no irony that Bach attended the same school in Eisenach at which Martin Luther himself had, for a period, been educated. As any one who listens to Bach’s cantatas and, in particular, the amazingly intense St Matthew’s and St John’s Passions, would instantly acknowledge Bach’s religious music is no simple professional undertaking. It is the product of a profound and very personal religious faith.

The third observation is the gap between the reputation of Bach today compared to how he was viewed in his own lifetime. Bach wasn’t totally unsuccessful. He managed a lifetime of gainful employment as a musician and didn’t die in penury like some contemporary composers such as Vivaldi. He was appreciated as a performer but less so as a composer and it took Mendelsohn, nearly a century later to revive interest in his music. When, in 1723, he was appointed to his final post as Kantor at the Thomaskirche in Leipzig, he was their sixth choice and in his later years he failed to secure a substantive post at the court of Dresden. Some of this may reflect his personality. Bach clearly had a temper and a not terribly well disguised streak of anti-authoritarianism but it also shows a profounder lack of appreciation of music which was then seen as complicated and old fashioned, but which today ranks amongst the greatest examples of human creativity.

The final thing to appreciate about Bach’s life was his familiarity with grief. Sometimes it is hard for us living today to understand fully the fragility of life in the past. Bach though had more than his share of bereavement. Both his parents died when he was a child. In 1720 his first wife Maria Barbara died while he was away with his employer Prince Leopold of Anthalt-Coethen at the spa town of Karlsbad. A profound sadness suffuses some of the most beautiful pieces of Bach’s music and I was interested to learn that the Fantasia and Fugue in G Minor, perhaps my favourite piece of Bach’s organ music, was composed shortly after Maria-Barbara’s death, in part as an expression of Bach’s own grief.

So, what is it about Bach’s music which makes it so special? I am not a good enough musician to understand fully the architecture and structure of Bach’s compositions but to me they always sound perfectly constructed in both tone and rhythm. Bach’s mastery of counterpoint and the way in which he seems able to throw themes against each other in perfect balance never ceases to amaze me and when I listen to his music, I need to do so with all of my being, mind, soul and body. It is no surprise that the appreciation of Bach so easily jumps cultures and genres. There is a particular love for Bach in Japan and, unsurprisingly, he is much admired by many jazz performers.

Beyond all his technical and intellectual brilliance however it has been, over the years, the emotional intensity of Bach which most captivates me. There is a lovely quote that talks about Bach’s music putting our insides on our outsides which for me absolutely describes how I feel when I hear some of his pieces, a few of which, now, I can not hear without welling up. In a few minutes Bach can summon up the whole of what it means to be human.

In my last blog I wrote about being shocked when asked by my son, on the day of my father’s funeral, whether I had decided what I wanted to have played at my own funeral. I was shocked by the question, but I did have an answer. It is the final chorus “Dona nobis pacem” from Bach’s B Minor Mass. Spend a minute to listen to it and it will put your insides on your outsides.

Time must have a stop – reflections on loss

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It is four months today since my father passed away. That time has been one of considerable reflection and, while I have written before in this blog on the need for society to talk more about death, I do so today with much more of a personal perspective.

Nothing prepares you for the death of someone close to you. My father’s death was in many senses not unexpected. He was 92 and had become increasingly physically frail. While he did n’t have a specific life-threatening illness he also had a strong intuition himself that his days were limited. Yet the end itself was a surprise, in part coming after a period of time when he had seemed to be getting better.

He had come home the day before but had been taken ill again in the evening and had to be readmitted to hospital. I went in with him but had to return home once he was settled to look after my mother. The morning after I had a call to come urgently into hospital.

When I arrived on the ward, I was taken aside to be told that he had died suddenly. It was a moment of profound shock. I remain enormously grateful to the staff, and in particular the staff nurse, on duty who dealt with that grief and shock in such a compassionate and professional manner. To handle such issues day in day out in the way she did takes very special qualities.

I sat with Dad for 15 minutes, only a curtain separating us form the normal bustle of the ward. In that moment of shock, I had a strange sense that, despite what I knew, his eyes might yet open again. It is the touch of cold hand perhaps more than sight that tells us definitely that someone has passed.

The rest of the day was very raw. Nothing I have ever done in life has been as difficult as telling my Mum that her husband of nearly 66 years had died. The immediate support of family, neighbours, colleagues and friends was very comforting. In the modern world I found it very helpful to share the news on social media and gained much from the messages of sympathy I received back, in particular from those who, themselves, had experienced a recent bereavement.

It seems to take a much longer time now to arrange a funeral than was the case when I first experienced such things. Dad’s took place three and a half weeks after his death, but the wait was helpful and the funeral itself was a very special occasion. Dad’s religion and nationality gave a clear and special focus to the occasion which not everybody has.

While he hadn’t left any particular instructions, we had a very clear idea of what he would regard as good funeral. Best of all, the chapel for the service was full, something I had really wondered about knowing that so many of his own generation had themselves died. Indeed, perhaps the most lovely thing about the whole experience was learning how well respected and liked Dad had been in so many areas of his life, indicative of a man was outgoing and community minded but who was fundamentally modest. Interestingly in many of the conversations I had inviting people to attend the funeral it was not always what people said but more the pause after I had shared the news which did as much to communicate the regard they had for him.

I am not sure this experience has done anything to strengthen in me any fundamental belief in an existence after our physical death but there is no doubt of the way in which the voices, thoughts and presence of those whom you have loved remain with you in a very tangible manner after they have passed. I have thought of Dad a lot since his death and moments of sadness that he is no longer there come upon you when you least expect them. This afternoon I am very conscious there will be one. For years after virtually every Welsh game I would call him to share our joy or disappointment at the result. It is inconceivable that I would not have done so after the Grand Slam match this afternoon.

The experience of the last couple of months has reinforced me the importance of talking more about death as individuals and as a society. We need to recognise more its inevitability and be more humble in respect of our perpetual efforts to extend life. Inevitably the death of a parent reminds you of your own mortality although it was a slight shock to hear one of my sons ask me after the funeral, which he had found very moving, whether I had decided what music I wanted at my own funeral.

What a greater acceptance and openness about death also teaches us is to focus on the importance of the present and on the value of living this day as if it were our last. That is a good lesson for as Shakespeare gets Hotspur to say in his death speech in Henry IV Part 1:

“But thought’s the slave of life, and life time’s fool; And time, that takes survey of all the world, Must have a stop'”

Quality questions

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It’s not always possible, as a Chief Executive, to have the time for reflection. I am sure the same is true for many front-line staff in the NHS too, taken up as they are by the immediate demands of patient care. Yet, at all levels, the moments for reflection are crucial if we are to improve what we can offer to the people who use our services.
So, this was a good week when I managed to get some genuine opportunities to think about the quality of what we do, first in a Board seminar on quality leadership led by the excellent Pete Dudgeon, one of the tutors on the Health Foundation’s Generation Q programme, and then in a number of sessions with staff from different parts of the Trust. Those sessions prompted to think about four questions.

The first was the terms in which frame the purpose of work on quality in ways which are meaningful to all parts of the organisation. I had heard of IHI’s “Triple Aim” but Pete helpfully introduced the idea of the Quadruple Aim in which, in addition to improved patient experience, increased population health, reduced unit costs the idea of improved staff experience was added as a fourth aim.

Particularly given where we are, at present, with the workforce challenges facing the NHS it is crucial we think about staff experience. We have spent too long with our foot on the floor, driving NHS efficiency through a focus on working harder. Thoughtful quality improvement is required if we are to find the sweet spots where we can make improvements work better for patients and staff. This, for instance, is where we should be focusing any debate about automation.

The quadruple aim also give us a frame for balancing the views of professionals and those who use service. It is no good trying to improve systems and processes of care if we miss the crucial point about how they are perceived by those who are on the receiving end. So, when we think that sending text messages to help reduce rates of DNAs are really helping patients remember the time of their appointments or are we adding to their sense of anxiety about something they are already in some sense of dread or denial about? We should not just assume, as professionals, we know the answer.

My second question is how we balance the tension between innovation and assurance. I remember a conversation in my last organisation about the nature of quality. We identified it came with two characters: “shiny eyed” – those special qualities of empathy and engagement which are so important in mental health work and “whittlearsed” – the constant attention to detail which can be very crucial in keeping people safe. The real trick in healthcare is that we have to do both, especially when we operate at scale and when we are trying to reduce unwarranted variations in care. We need to think much harder about how we build these contrasting but equally important skills both into the training and development of individuals but also into our concept of well-functioning teams in healthcare.

The third question relates to how we manage the containment of anxiety. Health care can be an anxiety provoking business. There is a lot which can go wrong, and the consequences of mistakes can be significant. By definition the environment is emotionally charged and when mistakes are made there is a natural tendency either to seek or avoid blame. Anxiety is a natural human instinct. It helps us respond to difficult situations and protects us from complacency but when it gets out of hand it is very destructive. Our struggles with managing and containing anxiety are, for me, at the heart of why the NHS has such a significant issue with bullying and harassment. It is an issue which we need to be much more honest about and look for systemic answers to rather than just seeing it as an issue of individual conduct. Good supervision and reflective practice which allow the non-judgemental sharing of problems and anxieties are crucial.  Important too is the responsible of senior managers like me to have a proper sense of the key anxieties for  front line staff in our organisations.

My fourth and final question is on how we learn and the importance of stories. It is right that the NHS is becoming more focused on the effective use of quantitative data and systematic systems of analysis. However, when it comes to learning I have long felt that it is stories which are the most effective vehicles for conveying lessons in ways which really make a difference. It is one thing which, from experience, the voluntary sector is really good at in terms of how it formulates its narratives about what needs to change or the impact which the right care can have on individuals. Stories also help us bring out the humanity which remain at the heart of healthcare, however technically sophisticated its delivery becomes.

It was Voltaire who we should be judged by our questions not our answers. The fascination of good quality improvement work in healthcare is in helping us constantly to be asking questions about what we are doing. It is there that the greatest scope for changing things for the better.

We need a bridge

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Politics is rather depressing at present. The Brexit debate seems to oscillate between Groundhog Day and a disaster movie. As a country, we seem to have lost the ability to have a rationale debate about the things which most matter to us.

In Welsh there is a lovely proverb “A fo ben, bid bont” which translates “To be a leader you must be a bridge.” It seems to represent the qualities we most need, at present, in our national life but also illustrates a wider point about what is required in leading in times of change and conflict.

One of the most difficult outcomes of Brexit is that it has created deep seated divisions between different sections of our society. While it should be accepted  that some of the essence of those divisions existed before they have now come into a greater and paralysing focus. The job of leadership, at the present time, must be to try to create some means of moving forward and reconnecting our society.

There are precedents in history to look at which give some examples of how this is done.

Ireland has featured a lot in the Brexit debates, often, in some quarters, with a sad lack of remembrance of quite how polarised views were across the sectarian divide. The Good Friday agreement remains one of the most substantial political achievements of my lifetime which required leaders from different parts of the conflict to find ways of abandoning conflict and working out a way of living together. In doing so many parties had to take some substantial risks and everybody had to give up something to get there. The road to a settlement was not easy and not everything is perfect now, but it did end a terrible conflict which claimed thousands of lives in Ireland and Britain.

Similarly, with the end of Apartheid. Thirty years ago, it was difficult to conceive that it would end, and, if it did, that it would do so without a bloodbath. The figure of Nelson Mandela, more than any other, epitomised the leader who was willing to become a bridge, never better demonstrated than in his iconic appearance at the 1995 Rugby World Cup wearing a Springbok jersey.

Post War Europe also showed such a spirit with far sighted individuals such as Jean Monnet and Robert Schuman who looked to find ways of fostering co-operation between France and Germany. Other bridgebuilders such as American Secretary of State, George Marshall and Winston Churchill helped create the circumstances in which Europe was able to move on from the disastrous conflicts of the 20th Century. That was so unlike the actions around the Treaty of Versailles in 1919 which, in settling the outcome of the First World War, so obviously sowed the seeds of the Second.

So, what is required to be a bridge? I think there are a number of qualities.
The first is a willingness to understand the other side, to recognise the beliefs or grievances which lead to people taking a particular position. In doing so it is important to treat people with respect wherever that is possible. Symbols such as Mandela’s donning of a Springbok jersey can be very important. In the Brexit debate I strongly believe a unilaterally generous attitude from the outset towards EU nationals already living in the UK would have done much to cultivate greater acceptance of the result of the Referendum.

Relationships across the divide also help and peace is often a double handed or multi-handed process: Mandela and de Klerk in South Africa, Gorbachev and Reagan at the end of the Cold War, Rabin and Arafat in the Middle East are good examples. On a smaller scale, in my own work, the development of relationships between those who have historically had to compete for resources has been keen to making progress in developing and integrating care.

The second is perseverance. Deep seated divisions are never solved by a single act. Trust, although it can be lost quickly, has to be built up over years. There were many twists and turns to the Irish peace process and much need for patience (at least in private) as initial optimism was dashed by the twists and turns of events. It was also interesting to note the recent commentary about Welsh Devolution and the work which Ron Davies, the Welsh Secretary at the time, had to put in after a very close referendum with both sides of the debate to ensure its acceptance.

The third is a readiness to take some risks. In politics that may involve tolerating divisions in one’s own ranks in order to achieve an outcome which is best for the national interest. The actions of Robert Peel around the Corn Laws, driven very much by principle, in part in response to the Irish Famine, saw a split in the Conservative party, but in those circumstances, Peel was right to put country before party.

The fourth is strategy. It needs some imagination to bridge the most serious divides in a society. It also needs clear attention to the detail on which deals, and compromises can founder.

Our current national challenge illustrates the importance of leading in ways which create a bridge across a divided society. It is quality of leadership which however goes much further. It is the first question we should ask of those who aspire to be leaders.

A significant moment for the NHS – a response to the Long Term Plan

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In a week in which the British ship of state looks otherwise to be floundering on the rocks of Brexit, the NHS Long Term Plan stands out as a really good example of where coherent and thoughtful policy making can add real value to the development of a crucial area of national life.
While in other cases I am grateful for the succinct summaries produced by thinktanks and representative bodies, on this occasion I thought it was important that I read the whole document. It is likely that this vision of the NHS will set the backdrop for the rest of my career in the health service and I feel it is important to reflect on its implications both those which I strongly support and those where I may have more doubt and uncertainty.

My first welcome of the plan is in respect of the very fact that this is a genuinely long-term plan. I have often made the point that there was one word in the Five Year Forward View which I disagreed with and that was the word “Five”. A system as large as the NHS needs a significant amount of time if it is to achieve a major transformation in practice and more importantly culture. Too often, and sometimes this has been a product of the political nature of our system, policy initiatives have been too short term to make any fundamental difference before the next big idea comes along. There is a chance that the Long-Term Plan, building on the vision already set out in the Five Year Forward View will have enough turning room not to fall victim to the same problem. While those arguing for change will always want things to happen more quickly, I think it is laudable to see a national policy document where many of the major commitments are placed firmly in the middle of the next political cycle (or indeed the one beyond that).

The Plan contains many individual ideas and proposals but there are a couple which stand out as particularly significant.

Without a doubt the jewel in the crown for me is the commitment to close the treatment gap for children and young people’s mental health by 2028. This more than anything else has been the hallmark of the lack of parity of esteem enjoyed by those experience poor mental rather than poor physical health. As a society we have always championed the young person who is unlucky enough to get cancer, we have very much failed to do so for the young person with severe anxiety or eating disorders, particularly in recent years when there is a clear and worrying increase in the incidence of mental health problems amongst that group.

The focus on schools-based provision is also positive. It will be crucial that we develop models of support that are not unduly focused on medicalising difficulties. Our measure for success will be the wellbeing of young people and their educational and other achievement, not just the numbers of treatments we deliver.

I am also pleased to see the commitments made in other areas of mental health, and in particular to strengthen crisis and community support for people with severe mental illness. This has been an issue which has been powerfully championed by former colleagues at Rethink Mental Illness and many others.

The next big idea I wanted to applaud was the commitment to transform the current model of Outpatients. It is not before time. No part of NHS delivery looks so feels like it’s still stuck in the 1950s and it’s a major driver of increased demand on the system. For me there appears to be a big opportunity, both to challenge the necessity of some outpatient activities but also to substitute others through the use of technology. Nearly years ago, when I was at NHS Direct, we piloted the ability to deliver a significant number of outpatient appointments by phone. The model work in terms of clinical practice, although less so in terms of hospital economics. With developments in technology there is scope to go even further if there is the will to do so.

The third big area I wanted to highlight is the clear policy, more possible in a ten-year plan backed by some new resource, to rebalance the system towards primary and community services and mental health. The commitment to see differential rates of increase in funding for these services is absolutely fundamental to any attempt to move care away from hospital. No doubt as a mental health champion I would wish to see the rate of change to be quicker, but I recognise the need for a smooth transition for the system as a whole. Nonetheless it is a very important step forward.

So, what are the possible downsides. The biggest point, which lots of other commentators have highlighted, is the relative absence of social care and the uncertainty relating to the future direction of social care funding. For the moment I am content to wait for the Social Care Green Paper but with the acknowledgement that without the courage to address this properly the NHS Plan will be undeliverable.

Workforce too has attracted a lot of attention. The plan is not silent on this issue, but we have to recognise that the last 10 years has left us with very significant challenges on workforce not only in terms of numbers but also more underlying issues of morale which will not easily be solved. We have at least recognised the scale of the issue.

My final point is that while there is much to support in the Long-term Plan, I have a concern that we could still be locked into too much of a world of medically driven, single disease paradigms in how we shape the future of our health service. As my own recent family experience of care has taught me the reality of life, especially for frail elderly people, but also many other groups, is more complex. We need a system which is not only integrated in terms of delivery systems but also in its philosophical understanding of the nature of human suffering.

Care and medicine

 

General-ward-2Now that some time has passed since my father’s passing, I wanted to write a blog on his last experience of the health and care system. In many ways it was a good one and it was certainly full of lots of individual examples of care. Nonetheless, it highlighted for me some of the real challenges of designing a system of integrated care that meets the needs of frail elderly people. Seeing this from the perspective of being a carer was immensely powerful.

As ever, there are things you see with hindsight which you are never aware of when we events are playing themselves out. Until the end we had little understanding that this could be the end of life for my father. His admission, however, at the end of October did quite clearly highlight that my parents were unlikely to be able to continue to live at home without some significant level of support. Our hope was that some time in hospital would help stabilise his condition while we arranged care at home.
In the end these objectives did appear to be achieved and my father was discharged.

However, sadly, his condition deteriorated again, and he had to be readmitted. Shortly afterwards he died.

In looking back at the experience of those last weeks with my father a couple of things stand out.

The first was the value of local care. I know well the arguments for rationalising specialist services in terms of patient safety and clinical outcomes but the difference between a local hospital (in my parents’ case a mile away) and a more distant hospital in terms of sustaining regular contact and visits was enormous. Even with my help it would have been immensely difficult for my mother to visit the more distant hospital on a frequent basis. Those visits were immensely important to my father in keeping up his morale and also in keeping my mother going when he was in hospital. The trade-off between the concentration of specialist services and the value of accessible local care need to be seen through the eyes of frail elderly people not just middle-aged decision makers. It is an area where technology might be able to play an increasingly significant role in facilitating the best of both worlds.

The second point relates to communications and decision making. It never ceases to amaze me, even when you are a Chief Executive in the NHS, how disempowering the systems of the health service can appear when you are on the receiving end as a patient or carer. While some uncertainty is inevitable it should not be such a struggle to find out what are the objectives for an individual’s care. With a certain amount of persistence, I did eventually find out, but such a process ought to be more central to the delivery of care.

The third point relates to medicines. One of the abiding memories of my father’s last day in hospital is the enormous bag of different medicines (13 I think in total) he was given to take home. Some of those medicines had been very important in keeping him alive to the age he reached and, for the most part he had been good at managing them. However there did seem something absurd in the quantity and in some sense randomness of what, as man of 92, he was being given to take. There has been some focus on the dangers of polypharmacy in terms of the risk of counterindications but for me the issue seems to be more about how the system can work with a patient to review medications and identify a sensible number which they stand a reasonable chance of being able to take.

While he was in hospital one group of staff, I was very impressed with were the OTs. They seemed to have a plan and were purposeful and energetic in what they did. They engaged with Dad and worked with him to enable him to reach his goal of being able to go home. Part of what seemed good about them was that they appeared to have more local discretion and authority.  That seems an important principle if we are to deliver genuinely patient centred care.

My final points are more general. The first was a real first-hand sense of how difficult it still is for patients and carers to feel part of one effort with the hospital and its staff. There were moments where things worked better, and many staff tried to engage with us. Often the problem was with the system and the bureaucratic and impersonal way in which situations were handled.

The second point one relates to risk taking. As the ambulance crew picked my father up on his last night, they marked his experience as a failed discharge. Perhaps from a strictly medical perspective it was but with hindsight the fact that he was able to spend some of last day on earth at home was incredibly special. We need a system which can make some of those judgements on a routine basis.

Finally, as the title of this blog hints at, my father’s experience reinforced me the relative value of care over purely medical objectives, particularly in respect of a man of my father’s age.

To finish there is one final part of the story to tell. That is my gratitude to and appreciation of the compassion and empathy shown by the staff nurse on the ward who had to tell me that my father had died and who supported me in the time I was there. For me it was one of the most significant moments of my life, for her it was probably a regular part of her work. That act of kindness will be one I never forget.