Skip to content

We need to talk about Kevin

200x200_worried-parent_gif

As often seems to be the case in January, the NHS was back on top of the news agenda this week. At times for good reasons as when Theresa May made a speech promising to end the burning injustices surrounding mental illness, at times for less good reasons as Accident and Emergency Departments struggle to deal with winter pressures.   It is one of those moments when more fundamental questions are again raised about the future of the NHS.

We know the NHS is much loved and cherished by the public, the nearest thing the English have to a religion as Nigel Lawson’s oft quoted quip would have it, but it is also something we find, as a nation, difficult to talk about in all but the most banal platitudes. If put to the test, an overwhelming majority of the public would vote to keep the NHS but what sort of health service do we want and at what price?

The next couple of years are a critical time for the NHS as it faces the simultaneous challenges of growing demand, the consequences of austerity and the uncertainties flowing form Brexit.   For one I believe it’s time we took a more fundamental look at some of the key questions which face the service and its development to ensure that there is a genuine consensus across the political spectrum which can ensure we have a sustainable NHS which is fit for purpose in the 21st century.

There are a number of key questions which should be part of such a long term review.

The first, and most pressing, is to look again at the 1948 settlement so as to bring health and social care together as part of an integrated system of funding and delivery. Social care is fundamental to the care of some of the most vulnerable people in society, whether frail elderly people or looked after young people.   When it is not there, inevitably demand on the NHS increases, often at greater cost.   The issue is, at last, on the policy agenda and there is a wealth of work to draw on how this might be achieved, including the report of the Kings Fund’s excellent Barker Commission.

Secondly it is time to institutionalise the commitment to give parity of esteem to mental health. I, like others, was happy to welcome the Prime Minister’s speech on Monday on mental health but the laudable objectives she set out cannot be achieved if the underlying inequity in funding is not addressed.  As the LSE highlighted in their 2012 report “How Mental illness loses out in the NHS” the treatment of mental health problems accounts for 23% of demand on the NHS but receive only 11% of the funding.  I would accept that such a shortfall cannot be tackled overnight but a longer term settlement for the NHS might commit, for instance, to eliminating this differential over a ten year period with a fixed additional uplift for mental health in each year of that period.

The third issue relates to the shape and balance of services. The 5 Year Forward View, still a valid road map for the future of health and care services whatever operational difficulties the NHS is currently facing, is predicated on a vision of community care with hospitals playing a less significant role than at present. This is, of course, a journey which mental health has already been down and is, for me, the direction of travel which we must follow to deliver a sustainable NHS.  Whatever we think are the causes of the current pressures on A&E and other parts of the acute sector the one incontrovertible fact is that a year on year growth of 3% for hospital services is unaffordable.  While an adequately resourced and well explained model of care closer to home can be popular with the public, that support can be lost easily if community care is seen as care on the cheap and essential services are not available when they are needed.  This change needs long term and unambiguous political commitment and adequate transitional funding if it is to happen properly.  However, without it, our chances of sustaining the NHS for next 20 years are slight.

My fourth question relates to how we define the mission of the NHS. It might be thought that there was an obvious answer to that question but health care need is not an absolute quantum.  There are always choices to be made about priorities.  Beneath the surface warmth we all feel about the NHS there is a more complicated reality and some hard choices, often made now by default, about priorities against finite resources.  Of course the NHS is there to save lives but, for me, I would like to see a greater emphasis on improving life chances (for instance through increased investment in children and young people’s mental health services)  and relieving suffering in the decisions we make about the development of services.  When much of what we can do to improve lives, in particular in the area of mental health, remains unfunded we should not assume that all future medical developments can necessarily be supported.  I believe NICE has been, in general, a positive development in our health care system but I think there is a case for revisiting the basis it is given for making some its judgements.

The last point, of course, relates to funding. Just as health care need is not an absolute quantum there is no right answer for what level of funding the NHS should receive.  However there is a case for taking it out of the realm of day to day political decisions and linking the decision to an external benchmark such as the average spend for comparable European or OECD countries.  The NHS is, in relative terms, a cost effective system but it is striking that, over recent years, the spend as a proportion of GDP has been falling and the gap broadening in comparison to other developed economies.  In such circumstances something has to give.

Day in, day out NHS staff do some brilliant work supporting the millions of patients who seek its help.  However it is a system under strain.  Positive change, of the kind outlined in the 5 Year Forward view, is possible but it needs a broad political consensus with the proper engagement of the public and adequate transitional funding if we are to deliver a model of health and care which is sustainable.  How we do that is challenging in an era where politics has become so polarised.  A Royal Commission, as some have called for, might be one route but only if there is an absolute commitment across the political spectrum to implement its findings.

We do need to talk about Kevin.

 

 

Ten years a leader

DSC_0220

Monday 2nd January marks for me the 10th anniversary of becoming a Chief Executive.  The experience of leadership, first at Rethink Mental Illness and for the last 3 years at the Tavistock and Portman, has been a dominating part of my life since.  It seems appropriate, then, to offer some reflections on what I have learnt in that time.

The last 10 years has not been an easy time to lead any organisation in the sector I operate in with the long draining impact of austerity. It has meant that “the money”, always by definition high on any Chief Executive’s list of priorities, has dominated the agenda and limited, although by no means ruled out, some of the changes which one would have wanted to focus on.

But that is the nature of the task.  “Events, dear boy”, as Harald MacMillan was right to point out, are central to the fortunes of any leader.  How quickly you pick up on the significance or otherwise of new developments and adapt your thinking and strategy to respond to them is a crucial skill of being the leader of an organisation.  There can be many false positives, issues which for a short while seem important but, in the long term, turn out not to be, but adapting to what is truly significant is the mark of a wise leader.

After ten years as a Chief Executive I have learnt that the most important decisions you make are about people. In particular the choices you make about your team, both as individuals but also how you choose to work with and develop them as a group are crucial to your ability to deliver whatever objectives you set yourself and the organisation.   No Chief Executive, however talented, can do it all themselves and those who try to are doomed to failure.

A good Chief Executive should also be interested in advancing talent and leadership more widely across their organisation.  Developing opportunities across the organisation, making the organisation an attractive destination for those with ambition and building a wider leadership community, should all, in my view, be key priorities for any Chief Executive.  The development of future leaders is one of a Chief Executive’s most satisfying achievements and being generous in time and advice the best way of realising it

The skills of building relationships outside the organisation are also paramount. No organisation is an island and the most important issues I have worked on, as a Chief Executive, such as the fight against mental health stigma and the development of new models of care, have been the products of partnership working between organisations.  While partnerships need many ingredients to be successful, commitment from and good relationships at the top are fundamental.  For very good reasons I spend an increasing proportion of my time in this kind of work.

Different Chief Executives manage in different ways but a key dilemma is always around delegation. Intuitively letting others get on with the job is the right thing to do and no one person can ever be on top of every point of detail in their organisation.  However as a Chief Executive you can never delegate the ultimate accountability for what happens in your organisation and therefore you always need to have a sense of what is going on.  It always angers me seeing senior leaders implicated in scandals claiming that they cannot possibly be expected to know about what was happening at more junior levels in their organisation.  For me they are either lying or alternatively demonstrating a level of dereliction in their duties as a senior leader.  So a good Chief Executive needs to know their organisation, know where it is most weak, delegate responsibility but have systems for receiving sufficient feedback on what is happening whether good, bad or mixed.  Setting a culture of honesty and transparency is crucial here making it easy for colleagues to share problems and mistakes, at an early stage, rather than trying to hide them until it is too late to do anything about them.

The importance of choosing priorities and managing expectations is another lesson I have learnt in the last 10 years. Full of enthusiasm and ambition it can be easy to try to do too much and to make too many changes.  The most effective changes I have led have been a result of persistence, picking an issue and being prepared to champion it, in some cases for years.  It is very rewarding when, as a result, it is possible to stand back and notice a change in how things are done in the organisation which no longer needs your direct leadership.  There is also a profound need to be disciplined in how you decide to use your own time and increasingly, I find, energy.  It is crucial to spend your time on the things that matter most.

It is also crucial to find the time to get out and refresh your knowledge and understanding of the organisation and its activities and to give people the chance to meet you and share their concerns.  I have always regretted it when, at times, I have deprioritised these activities. The small things matter as well. The words of thanks and, at times, consolation, the time spent in engaging with the people in your organisation as people not just cogs in the wheel are sometimes the contributions which I am most proud of.

Being a Chief Executive can be demanding, lonely and, at times, uncomfortable position. It remains an enormous privilege, however, to lead organisations of the kind I have had the chance to lead, whose purpose is clear and where the commitment of staff to make the world a better place for people with mental health problems is so palpable.  If I’ve been able to do anything to make those organisations more effective and impactful the experience of being a Chief Executive, with all its stresses and strains, will have been more than worthwhile.

Merry Christmas?

XmasParty

 

Christmas is here and as the carol enjoins us “Tis the season to be jolly”. A time to put aside the preoccupations of our daily lives and “heedless of the wind and weather” revel in the Yuletide celebrations. But is it possible, in contemplating Christmas, to distance oneself totally from the events happening around one and reported through the incessant flood of breaking news.

By any standards 2016 has not felt a great year and this week’s events in Berlin have epitomised that sense of malaise in our affairs. For those families directly affected this Christmas will be an unexpected time of grief and for the rest of us there is a dull sense of revulsion of yet another heartless attack on ordinary people and an attempt to disrupt and terrorise the traditions of civic and civilised life.  The response to the attack from some quarters, is equally depressing, stirring up hatred not just of individuals but of whole groups and reinforcing the sense of terror which, by definition, it is the first objective of the terrorists to create.

In my professional life too this has been a hard year. The NHS, like many other public services, is, after many years of austerity, under considerable pressure.  There is much more to do as the demand for services increases and very little in the way of new resources to do it with.   A genuine interest in doing more to help people with mental health problems in society is struggling to be realised on the ground as promises to find new investment fail to materialise or are overwhelmed by the scale of unmet need for help.  Change and uncertainty abound and they alongside what there is to do create a sense of weariness and hedonic deficit.  I can scarcely think of a time in my working life when I have been so ready for a break.

In general I am one of life’s optimists, my temperament and by experience.  I like to believe in the possibility of positive change in both individuals and society and am not naturally pessimistic about human nature, although recognising history is full of examples of human folly and frailty.  The events of the last couple of years have, however, shaken some of that optimism.  Getting older is undoubtedly part of the piece, particular in a context where you have a sense of some of the things you have valued throughout life disappearing or being under severe threat. The relentless of the news and its enduring focus on the negative and shocking does not help either.

I am, unashamedly, a son of the Enlightenment, a supporter of the power of reason as opposed to fear and superstition, committed to values of openness and tolerance, delighting in difference and a believer in the possibility and reality of progress, of the elimination of suffering and the increase of human happiness and well-being. For most of my adult life, with some occasional moments of retreat, this view of the world has felt justified but at the end of 2016 it feels more threatened than I have known before.  That, inevitably, feels disturbing.

Other Christmases have been different. Our first married Christmas in 1989 was one when the events of the Velvet Revolution had engendered a wonderful sense of optimism in the triumph of hope over the stale and oppressive forces of tyranny.  Images of Berlin were central to that Christmas as they have been to this one but images this time of a totally different atmosphere and mood.

However, Christmas is a good time for reflection so what can it offer to counter some of the inherent gloominess of the times. There are a number of hopeful messages.

First the festival itself in its Christian and pagan manifestations recognises the need for hope in the midst of the depths of winter, for light in the midst of darkness, for a brief time of plenty before we face the time of shortage. This is a festival we have designed in the knowledge of our own need for cheer and encouragement.

Second, as I’ve seen lots of time in recent weeks on the streets of London, it brings out, most of the time, the best in us, encouraging acts of charity, an interest in the less fortunate and a wider sense of good will to our neighbours and fellow citizens.

Third Christmas brings us back to what matters most in life, to those closest to us, to our families, near and extended, and to our closest and oldest friends.

Finally Christmas has a sense of timelessness. A time to reflect on other times, on times of happiness or on times of previous difficulty which have passed and have been overcome.  From that can come sense of renewed purpose in facing the future.

So perhaps this year will not be a Christmas of total merriment but it is a season to be jolly and to aim and plan for what can be different in 2017.

The March of Folly

chargeofthelightbrigadecavalrycharge

The Alchemist by Ben Jonson is one of my favourite plays and the RSC production I went to see recently did it proud.

Written over 400 years ago, it still has much to say about human folly and our willingness, as a species, to deceive others and ourselves. The plot revolves around a trio of rascals:  Subtle, Face and Dol who use the absence of the Master of the House, Lovewit, during an outbreak of the plague in London to set up a number of outrageous scams to defraud their fellow citizens.

The play is no less harsh on the victims of the fraud as it is on its perpetrators. A series of characters are displayed who through their vanity or plain stupidity are easily lulled into going along with the promises and deceits of the three villains.  In the end their villainy catches up with Subtle, Dol and Face when Lovewit unexpectedly returns to the house but that is of little consolation to the victims.

The play got me thinking about the nature of human stupidity which once Einstein supposedly described as being with the Universe the only things that were genuinely infinite (although he had his doubts about the Universe). For a species distinguished by its cleverness and ingenuity it is striking how frequently our individual and collective history is coloured by episodes of folly.

From a historical perspective there are a number of distinct “types” of stupidity.

The first is what I would call the “free lunch” syndrome, the idea that there is an effortless path to wealth or success. For Sir Epicurus Mammon in the Alchemist it is the belief that the Alchemist can turn the base metal of his kitchenware into gold but how much more stupid is that belief than that which encouraged investment into sub-prime mortgages before the 2008 Financial Crash.

The second type is more subtle and relates to “cognitive dissonance”. First identified as a phenomenon looking at radar operators during the Second World War it relates to our inability to accept new pieces of information which undermine our fixed beliefs.

If cognitive dissonance is an essence a process of the unconscious there are cases of more deliberate stupidity when we chose explicitly to ignore facts or arguments which are inimical to our beliefs, values or interests. In this case we are prepared to deny rational argument or give unthinking support to those who provide an argument which is better aligned to what we want to believe.

There are times too when, privately, we can accept that the facts have changed but, in public, there we lose too much face in accepting that we were wrong and that we must change a course of action. Politicians and Governments find this particularly difficult where admitting a mistake or false belief is seen as a particular sign of weakness.

As a social species collective beliefs and behaviours are crucial in defining acts of stupidity. Peer pressure and group think play an enormous role in what we think and how we behave.  It is much easier to adhere to a majority belief than to be a lone voice opposing the group position.  The fate of the Trojan princess Cassandra sums it up entirely; the horror of being always right but never believed.

While education should be a protection against acts of stupidity, sadly this is not always the case. Indeed from my experience there is nothing worse than seeing a clever person, especially in a position of leadership, trapped in a position of stupidity.  Their intellect and education can give them an armoury of arguments with which they can defend their views to themselves and others.  At the end of the day, however, they are still wrong.

So how can we guard ourselves against being the victims or perpetrators of folly? There are no perfect answers but there are some things which might help.

The first is history and our sense of belonging to it. When things go wrong professionally or personally it is always amazing how easily a sense of hindsight can tell you what you should have done differently in a way which would have been almost impossible to determine at the time.  History is our collective sense of hindsight and history is littered with the signs of folly. Indeed one of my favourite books is the American historian Barbara Tuchman’s  ”The March of Folly” which analyses a series of historical episodes from the Fall of Troy to the Vietnam War to demonstrate how much stupidity has determined the course of events.

This is one of the reasons why a lack of respect for history in modern times so saddens me. Just because we have i-phones does not mean that we have disconnected ourselves from the patterns of events and behaviours which have repeated themselves over the generations.  Recent political events in Europe and the USA only confirm the point.

The second protective factor is inquisitiveness. However much we know we should always be looking for new information and insights, including, challengingly, those which may be at variance with our beliefs.  Sometimes, when we are least expecting it, we can see the “pearl of great price” which the poet R.S. Thomas refers to in his beautiful poem “The Bright Field”  which provides real insight into what is happening and can force us to change our minds.

The final quality required to guard against stupidity is humility. It is never easy to admit we are wrong, to back track from long held beliefs and to change our course of action. It is particularly difficult to do so in positions of leadership and, sometimes, one cannot expect to do so without personal cost.  The dictum of J.M. Keynes must be right though “When my information changes, I alter my conclusions. What do you do, sir?”

So all in all, Ben Jonson’s drama of human folly set in London in 1610 is all too relevant in London in 2016. The March of Folly continues but perhaps there are some things we can do to slow it down.

The other kingdom – a farewell to summer

dsc_0075

 

Autumn always comes with a jolt. August turns to September and we’re back to the busy schedule of work and school with the prospect of the long slog to Christmas.  A brief moment of peace over the summer is finished for another year.

This year has been no different. Back from a wonderful holiday in the Austrian Alps it has been straight back to the demands of the STP and all the challenges of running a NHS organisation in the current climate.

Summer holidays have always had a very special place in my consciousness. Much to the annoyance of my family, I can remember the things I have done on the holidays over the years with an intensity it’s hard to bring to other aspects of my life.  They are enjoyed in anticipation and retrospect just as much as they are at the time and it is always important for me to finish the summer with a clear idea of where we will be going next year.

Holidays serve many purposes. At their most basic they serve to provide a period of rest and relaxation, a chance to down tools and recharge the batteries.   That is a very necessary objective and we are all the better and more productive for being able to rest from, time to time, from our work.  If God needed to take a day off after the labours of creation it stands to reason that mere mortals should follow suit.

Holidays can also be the opportunity to indulge in pursuits for which there is insufficient time or occasion to follow at other times. In particular they are the time for reading and my holiday luggage is always weighed down by an enormous pile of books, some of which, at least, I manage to get through.

Holidays provide the chance to learn about new places and immerse oneself in new cultures and new histories. With a lifelong love of history I have always enjoyed stomping around archaeological sites, historic monuments, museums and art galleries, relishing the opportunity to see both the special places I have long heard about but never previously visited and the new discoveries which open a new strand of interest.

As a child many of my summer holidays were spent staying with relatives in Wales.  Without their hospitality we would have probably struggled to go away and I am enormously grateful for those times which in addition to being great fun, cemented my love of Wales, its people and landscape.

In my youthful imagination there was something very special about the views of the mountains of Snowdonia across the Menai Straits from Anglesey, the Edwardian castles of Beaumaris and Caernarfon, the grey stoned chapels which peppered the roadsides, the open skies and the foam speckled sea. It expanded the bounds of my imagination and contrasted so strongly with the mundane everydayness of the city I grew up in.  Being Wales there were many rainy days but if anything they did as much as the sunny ones to engender the sense of otherworldliness associated with those childhood holidays.

This potential of holidays to provide an opportunity to escape not just from the practical details of everyday life but also from its imaginative constraints is something which still remains with me in middle age.  It is the time I feel again that sense of open possibilities, so easy for a child for a child to envisage and so much harder to recapture in later life.  A good summer leaves one refreshed and rejuvenated both physically, psychologically and imaginatively.

However, like all good things in life holidays inevitably come to an end and, in doing so, bring a sense of grief and loss. This year we visited the Wörthersee in Austria where Gustav Mahler took his summer holidays and wrote a number of his symphonies in a small composer’s hut overlooking the lake.  On the walls of the hut there was a quote from Mahler which captured the sense of sadness when the time came to leave his summer idyll and source of inspiration.

“Today I go away from here with a bitter heart. To know one must wait another year is tragic.”

As I left that special place it summed up feelings exactly.

 

Necessary but not sufficient – the role of regulation in health care quality

The-Tavistock-Clinic-in-North-London

 

In the first six months of this year I experienced CQC inspections as both the Chief Executive of an inspected Trust and as the Chair of an inspection at another Trust. I found it a fascinating experience being on both sides of the process and it prompted me, once both inspections were completed, to want to write about that experience and my views on where regulation sits in ensuring high quality health and care services.

CQC comes in from time to time for a bit of criticism. I, however, found the process of inspection on both occasions robust and fair.   Post Francis it was inevitable that the regulator needed to adopt a more intensive process and I am probably, in any case, a supporter of a “boots on the ground” methodology as long as it is used proportionately.  From my perspective there is much to be gained from an inspection team visiting services and meeting front line staff and service users as well as relying on external or internal data.   The CQC process puts a lot of emphasis on the triangulation and corroboration of evidence to reinforce the validity of the judgements which are made.  I welcomed the involvement of peer specialists and of experts by experience and the very significant added value they both brought to the inspection process.  Finally the methodology rightly allows for a focus on good practice as well as the more rule bound aspects of quality.

Inspections are like visits to the dentist.  Nobody enjoys them at the time but they are necessary to the health of the system. There are also clear benefits to the organisation being inspected if the process is embraced in the right way.  At my own Trust the process of preparing for our CQC inspection was very powerful in helping us draw together the strands of our quality work and in ensuring good engagement with front line clinical teams on key issues.  The report, both its validation of what we do well and the recommendations of where we can do better have been helpful in driving our decisions as an organisation of where we go next.  I could see much the same at work in the organisation I was part of inspecting and very much welcomed the open way in which the senior team at that Trust received our findings, both good and bad.

In a system as complex as the NHS there will always be issues with any system of quality regulation. When the reputation and, at times, the future of senior individuals and organisations hangs on what is said by the regulator there will inevitably be tensions about negative judgements and ratings.   CQC focuses on providers and providers may feel hard done by when the fundamental issues behind the judgements made about their performance relate to factors out of the provider’s direct control. This is particularly an issue when there is a blatant mismatch between the levels of demand providers are trying to manage and the level of investment made by commissioners.  In an environment which is increasingly putting more and more emphasis on system performance it is appropriate that the focus of regulation should shift more in that direction.  How to do so is still very much to be worked out.

Another unforgiving aspect of inspection is that judgements have to be made on the basis of what is seen at the time not what might be intended to happen in the future. That can be harsh on organisations where there is a genuine engagement with quality improvement but where there are major structural or cultural issues still to overcome.  Whatever is said in the report a good inspection process will explain the context to judgements and recommendations and give recognition to the efforts of clinical and managerial leaders to tackle underlying issues.

From time to time there has been a debate about whether the strengthened system of inspection has been the right answer to the concerns about quality identified in reports about Mid Staffordshire and Morecambe Bay. I firmly believe that a robust system of inspection is a necessary feature of a good quality care system and that CQC’s regime, while it has room to develop and adapt, is fit for purpose.  However at the same time inspection and regulation cannot be the only mechanism for ensuring and improving the quality of care.

First and foremost quality needs to be owned by the Boards and leaders of organisations.   That ownership should be reflected in the amount of time devoted to quality in Board discussions and the level of inquisitiveness which Executives and Non-Executives have about what is really going on in their organisation.  Wherever an organisation is in its quality journey a good inspection report should bring few surprises to the leadership of an organisation.  If it does that is a judgement in itself.  Boards should be prepared to invest in quality improvement.  They also need to understand the implications for quality of other changes and pressures in their organisation and have an acute sense of where their “red lines” will be in terms of the risks of compromising quality.

However quality also needs to be owned by the system and not just seen as the business of providers. Improving quality is not always a question of additional investment but at a time of rising demand it is likely to have financial implications.  One of the key roles of the regulator must be to provide an independent voice for quality standards with the willingness to “blow the whistle” when financial expediency potentially compromises the quality of care received by patients.

A regulator of quality is an essential component of a high quality system of care and if CQC did not exist it would have to be invented. It needs to do its job well and with integrity and now as much as ever it needs to be uncompromising in championing the voice of quality against other pressures in the system.  However no one should assume that, on its own, CQC can be the guarantor of good quality care.  That is all of our business.

 

All Quiet Now on the Western Front

dsc_0107

Over the last week I have cycled some 500 miles along the line of the Western Front in the First World War. It’s been a trip I have wanted to make for some time and has been a powerful way in which to experience the landscape in which this terrible conflict was played out.  In my panniers I carried, as well as maps and guidebooks, a volume of the First World War poetry as an emotional and psychological guide to what I was seeing.

Cycling is a perfect way to appreciate any landscape.  You travel slowly enough to be able to observe the terrain around you and you do so with all five senses.  You are acutely aware of gradient and intuitively stop at the top of any major climb to admire the views in front and behind you.  You also travel fast enough to be able to see the changes in landscape and the subtle differences between areas and regions.  You can travel far enough in a week to make sense of an area as large as that in which the First World War was fought.

I started in Belgium to the north of Ieper. Belgium was the little country whose fate was central to this becoming a World War.  It was the official reason for Britain joining the conflict and the fate of Belgian civilians featured strongly in the recruiting propaganda of Lloyd George and other British politicians. For most of the war only a small part of the country remained in Allied hands but it was interesting to visit Belgian cemeteries and see memorials to the sacrifice made by Belgian soldiers to the war effort.

Cemeteries dominated the route. I stopped at lots and I have no idea how many I passed. There is a particular character to First World War cemeteries.  They are scattered across the landscape because they reflect where men were buried at the time of battle.  In many cases they stand alone at the roadside or across a field but in other cases, for instance the cemetery which I visited in Arras where the poet Edward Thomas is buried, they are surrounded by more modern buildings.

There is a powerful uniformity of design to the cemeteries: gravestones in serried ranks as if they are on parade. They are all immaculately maintained and there is an order and purpose in these places in such stark contrast to the circumstances in which many of those buried there ended their lives.

Some soldiers have names and ranks and others are anonymous, euphemistically in English “soldiers of the Great War known to God”, in French much more brutally “inconnu”.  Yet despite this there is an irony that the occupants of these graves are better remembered than many others who have died before or since.

The cemeteries and memorials I passed also reminded me of the range of different backgrounds, nationalities and religions of those who took part. I stopped to see the beautiful memorial to soldiers from the Indian sub-continent at Neuve Chapelle (and next to it a cemetery for Portuguese soldiers), the Irish Peace Tower at Messines (commemorating the place where Catholic and Protestant Irishmen first fought alongside each other in 1917), a memorial to Australians at Peronne, another to South African troops engaged in action at Delville Wood during the early weeks of the Battle of the Somme, a monument to the Basques and, as might be expected, memorials to Welsh troops at Langemark near Ypres and to the 38th Welsh Division at Mametz Wood on the Somme.

One of the most striking cemeteries I visited however was further south on the Chemin des Dames in the French section of the front. At Cerny en Laonnais French and German cemeteries are placed directly alongside each other.  I had a sense of young men, motivated to fight each other by many of the same values of patriotism now lying at peace next to each other.

La Chemin des Dames, a long ridge north of the Aisne Valley fought fiercely over during the whole period of the War, was one of a number of places which brought home to me the importance of high ground in this conflict. My route also took me over Vimy Ridge taken the Canadians in 1917.  It was staggering, as I struggled to get up them on my bike, to think of soldiers attacking these positions under heavy fire.

One of the most moving things I saw was right at the beginning of my trip. In Poperinge near Ieper (and just behind the British lines) it is possible to visit the cells in which British soldiers, convicted for desertion (some suffering from shell shock), were held the night before their execution and the yard in which they were shot.  Of all the brutal images in a brutal war nothing stands out as far.

The final image of my trip is that which I have used as the header for this blog. We are used to the poppy being the symbol of the conflicts of the 20th century but it was especially moving to cycle through the battlefields and see the poppies growing amidst the cornfields, such a poignant reminder of the lives of young men sacrificed a hundred years ago.

The guns are silent and all is now quiet on the Western Front. I thought that one thing which would have united young men from all the nationalities who lost their lives on these fields was that the horrors which they experienced would represent a war to end wars.  Sadly a hundred years I am not sure that we have learnt this lesson.