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The long shadow of Roman Britain

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I have had a lifelong interest in Roman Britain. When I was 6, having failed to visit the Roman site at Chester on the way back from a family holiday in North Wales, I decided, one Sunday morning, to take the law into my own hands.  Being the “intelligent clot” I am I knew that the A41 which went past the bottom of our road went all the way to Chester.  So I set off with a carrier bag with a drawing pad and a packet of custard cream biscuits.  I had walked two miles into Birmingham before my father found me.

46 years later I still find anything to do with the Romans in Britain fascinating and as my family know to their cost, it will take very little to divert me from wherever we happen to be going to visit some little piece of Romanitas, however far off the beaten track it may be.  Recently it’s been a great pleasure to discover someone else’s fascination with the subject while reading Charlotte Higgins Under Another Sky which describes her journey round some of the principal (and less principal) sites of Roman Britain together with some of the stories which surround those places.  It’s a great read and I thoroughly recommend it.

While there are one or two earlier references in other writers to Britain, the arrival of Julius Caesar in 55BC marks our country’s transition from prehistory to history, the first emergence of named individuals with some idea of what they did and said.  I always take a pleasure that it wasn’t any old Roman who first tried to conquer Britain.  He came, he saw and, of course, he didn’t quite conquer.  After two expeditions, of mixed success, he was forced to give up his ambitions and it wasn’t until 43AD and the Emperor Claudius that the Romans finally added Britain to the Empire.  They remained here for another 367 years until the Emperor Honorius was forced to call the legions home in 410AD and leave the British to their own devices.

As Charlotte Higgins brings out very well Under Another Sky an interest in Roman Britain is both an interest in the Romans and in Britain itself.  While militarily and economically one of the most challenging parts of the Empire the Romans nonetheless successfully brought the trappings of their civilisation to Britain.  Cities, roads, bathhouses, literacy are amongst the list of what the Romans did for us and while, with the exception of Hadrian’s Wall, the physical remains of Roman Britain are not as grand as those to found in other parts of the Empire the lasting legacy of the Romans is still with us.  It is probably the Romans who first defined Britain as a distinct geographical and cultural entity and who initiated many of the reference points which are still very important references for our cultural identity.

Our capital London is a Roman foundation, for a while one of the most significant cities of the Empire as it became the centre of the grain supply for the Roman army in Germany.  The essence of London as the administrative and economic centre of the country is a Roman creation and many of the main roads leading out of the capital still follow the lines of their Roman predecessors.  Furthermore our relationship with Europe is still underpinned to an extent by the shadow of having been part of the Roman Empire.   Finally, while no one should idealise the motives and conduct of Roman imperialists they were the first to bring an idea of “civilisation” to this country.

While the Romans would have definitely recognised the economic fault line between the North West and South East halves of the country  Roman Britain is not just about the South East.  The military investment in maintaining the northern frontier of the Empire at Hadrian’s Wall and, at times beyond, ensured that Roman life and Roman civilisation was well established in northern England as well.   York, a crucial staging point on the Great North Road, was an important Roman city where two Emperors died and where one, none less than Constantine the Great, was proclaimed.  The discovery of the wonderful Vindolanda tablets (from one of the forts on Hadrian’s Wall) show Roman civilisation alive and well on the very edge of the Roman world.  It is impossible not to be moved by the birthday party invitation sent from the wife of one of the senior officers of the unit based at Vindolanda to one of her friends.

It is this sense of distant, but yet at times quite intense, connection with the inhabitants of Roman Britain which make I spent a large part of my University summers working on archaeological excavations at two Roman cities:  Wroxeter in Shropshire and Silchester, near Reading.  In both cases the cities were abandoned at the end of the Roman period (although in the case of Wroxeter much later than was originally supposed) and they are again green fields.  In both there is a lovely haunting sense of the shades of the ancient Romans who went about their business in these places, looking at the same sky and the same scenery.  AE Houseman captures this perfectly in the line in his poem about Wroxeter

The tree of man was never quiet:

Then ‘twas the Roman, now ‘tis I.

The gale, it plies the saplings double

I t blows so hard it will soon be gone.

Today the Roman and his trouble

Are ashes under Uricon.

Like the Romans we will, at some point, all become dust but it does not mean that our time on this earth is without meaning.   Roman Britain is a distant but significant period in our history.  Despite all that has happened since, it has contributed to our identity and values and is worthy of our interest and reflection now.

Parity of esteem must be an enduring priority

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The ambition of “parity of esteem” between physical and mental health was one of the significant contributions of the Liberal Democrats to health policy in the last Parliament. It has been a frustrating concept, at times, because of the gap between the aspiration which the phrase contains and the reality of services and budgets on the ground at a time of austerity. It did however, for me, capture a laudable and crucial aim to put mental health centre stage in our health and social care system and to address the appalling long term and structural inequalities faced people who experience mental health problems in accessing help. While champions such as Norman Lamb and Paul Burstow are no longer part of Government it is crucial that new Ministers and other senior leaders pick up this mantle, first, because people with mental health problems deserve it but secondly because it is a fundamental part of sustainable health and social care system in this country.

The NHS has always treated mental illness as a second class problem and an area of expenditure which is easier to cut than A&E or cancer when savings have to be made. Despite the political commitment there has been on the issue, there has been clear evidence of disinvestment from the sector, the most recent estimate from Community Care suggesting that this has been as much as £600m or 8% of total budget over the length of the last Parliament. NHS Providers’ recent report “Funding for Mental Health Services: Moving towards Parity of Esteem” indicates that this year has failed to reverse the tide despite the strongest injunction I have ever seen in national guidance to increase mental health spending in line with the overall increase in allocations received by CCG.

There are many reasons why it’s hard to do. Many CCGs, or their acute providers, are already facing significant deficits and pressure on key performance standards such as the 18 week wait or the 4 hour wait in A&E inevitably focus attention away from less visible gaps in services in areas such as mental health. From 2016 mental health will, for the first time, have its own waiting time targets for access for treatment for anxiety and depression and to early intervention services for people with a first episode psychosis. These are welcome developments and it must be a continued priority in the next 5 years to see an extension of the kind of guarantees of access to services for people with mental health problems as we take for granted for physical health problems. Progress will not be without cost and it is crucial that additional resources, such as those promised for children and young peoples’ mental health promised by the last Government, reach the front line. Simon Stevens leadership on the issue has been helpful and I very much hope that the Taskforce he has established, chaired by Paul Farmer, will add to the case.

But a priority around mental health goes much further than just traditional mental health services, important though they are. The proper consideration of mental health as a central component of the model of integrated care is also crucial if the kinds of benefits envisaged in the Five Year Forward Year are to be properly realised. Some progress has been made in work on both the Better Care Fund and New Models of Care to bring mental health to the table but that is a long way further to go.

There are three dimensions to this issue which between them have a massive impact on how our wider health and social care system operates. First there is the issue of co-morbidity where mental health issues such as depression, anxiety or dementia set alongside physical health problems, restricting recovering, reducing wellbeing and contributing to frailty and risk. Many such patients currently receive no help for their mental health problems despite an excess cost to the NHS of failing to treat these symptoms estimated by the Kings Fund and Centre for Mental Health of as much as £13 billion per year.

Secondly there is the issue of medically unexplained symptoms where psychological distress or other mental health problems can underlie the presentation of physical symptoms. Such issues might account for 1 in 3 patients seen by a GP and 1 in 4 patients in a hospital clinic. As services such as our primary care psychotherapy service working alongside GPs in Hackney show there are really benefits from providing psychological support for such patients, improving their outcomes and saving money in other parts of the system.

Finally there should be an important recognition of how psychological considerations impact more widely on individuals affected by illness and on care givers, both professionals and informal carers. Nowhere would this be truer than in end of life care, as anyone in the hospice movement would readily tell you. Better regard to such issues might well lead to better decisions about the utilisation of healthcare and more effective interventions when they are applied.

As I have argued in this blog there has never been a more important time to put mental health centre stage. It may have been the Liberal Democrats who coined the term “parity of esteem” but it is the duty of the new Government, NHS England and other senior leaders in the system to make sure, however difficult it is to find the funding, that there are concrete steps taken in the next 5 years to make it more of a reality.

A Shropshire Lad

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As someone educated in the classical tradition, the name of A.E. Houseman has been familiar to me for years but until this Easter I had never read his poetry.

Houseman is an interesting figure.  Born in 1859 in Bromsgrove he became one of the great classical scholars of his generation (and that was something in his generation) ending up as Professor of Latin, first at University College London and subsequently at Cambridge.  However, it was nearly not to be.  After winning a scholarship to St John’s College, Oxford and securing a first in the first set of exams there he completely bombed the second half of the course, leaving the University without a degree.  There is no clear rationale for what happened to him but an unrequited passion for his roommate Moses Jackson, appears to have been one factor. After Oxford he secured a job at the Patent Office and had to work his way back into academia through dint of private scholarship of such a quality that in 1892 he was offered the chair at UCL.

Houseman did not make much of himself as poet and yet he has become one of the best loved and evocative English poets of the late 19th and 20th century.  His first and most famous book of poems “A Shropshire Lad” had to be published, for the first time, at his own expense but have never been out of print since.  He only published only one other book of poems in his own lifetime “Last Poems”, which came out in 1922.  Further works were published, by his brother, after his death in 1936.

Despite his background as a classical scholar his poetry has a simple and very accessible quality.  Much of it has a melancholy tone and there is a sense which “The Shropshire Lad” foreshadows the writing of the First World War poets.  The theme of the soldier leaving for war only to find a grave in a foreign field is a frequent one in Houseman’s poems although, for him, this is part of a wider reflection on the transient nature of life rather than a commentary on a particular conflict.

Like other writers in this period Houseman is deeply interested in the English countryside, in his case that of Shropshire, which forms, in turn, both the setting and subject matter of his poems. I too have been fond of this county, sitting as it does on the route between Birmingham and Wales.  Houseman sees the landscape as the holder of perennial truths, an unchanging backdrop to the more ephemeral deeds of the human characters who pass through it.     There is a beautiful poem in the Shropshire Lad about the Roman city of Wroxeter.  I spent three summers myself working on excavations at the site in the 1980s and was held in awe by the powerful presence of the Wrekin on one side and Wenlock Edge on the other which would have looked little different for the Roman inhabitants of the city.  So Houseman describes a gale on Wenlock Edge and the feeling its creates as something shared by Roman and modern visitor alike:

The tree of man was never quiet:

Then ‘twas the Roman, now ‘tis I.

 The gale, it plies the saplings double

It blows so hard it will soon be gone.

Today the Roman and his trouble

Are ashes under Uricon.

Another set of poems contrasts the comfort provided by the familiar people and countryside of Shropshire with the soulless metropolis of London.  Houseman captures poignantly the deep sense of homesickness which many must have felt who have come from the country to the big cities of the world.

But here in London streets I ken

No such helpmates only men;

And these are not in plight to bear

If they would, another’s care.

He also writes some very moving poems about outsiders and those who, though fate more than anything else, have fallen outside society’s rules.  There is a powerful poems identifying with a young man condemned to be hung in Shrewsbury Gaol.

A better lad, if things went right,

Than most that sleep outside.

Another poem reflects on those who have taken their own lives:

Dead clay that did me kindness

I can do none to you

But only wear for breastknot

The flower of sinners’ rue.

A final, rather enigmatic  poem perhaps alluding to his own sexuality, describes the difficulty of living to other laws than those which society has ordained to be right.

And make me dance as they desire

With jail and gallows and hell-fire.

I, a stranger and afraid

In a world I never made.

A final theme which Houseman describes with great insight is the contrast between the naïve optimism of youth and the more worldly wise but ultimately sadder thoughts of the older man.  Houseman is deeply absorbed by the idea of death and the ultimate futility of human labour.  He retains however a fondness for the young person’s hope and for the fact that an endearing even if ultimately frustrated sense of hopefulness survives in each generation.  So in his poem “The first of May” published as part of his “Last Poems” Houseman describes how it is now a different generation which, just like his, make their way to Ludlow Fair on the 1st of May.

Our thoughts, a long while after,

They think, our words they say   

Theirs now the laughter

The fair, the first of May.

 

Ay yonder lads are yet

The fools that we were then;

For oh, the sons we get

Are still the sons of men.

German Wings

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Like many involved in the battle to change attitudes towards mental illness, my heart sank on Friday morning when, walking through Clapham Junction Station, I caught sight of the day’s newspaper headlines.  In language at the best sensationalist and in many cases judgemental and stigmatising they made the claim that the Tuesday’s tragic crash of the German Wings flight from Barcelona to Dusseldorf could be blamed on a man, the co-pilot Andreas Lubitz, suffering from severe depression.

So after years of improving attitudes and improving media coverage, even in the tabloids, here we were back again in the bad all days where mental illness could be freely demonised and where gross stereotypes could be applied to those affected.  I have always disliked the kind of media scrum which follows a high profile tragedy like Tuesday’s crash where the media chase after every possible detail and angle on the story and where the currency of competition tends to be expressed in terms of the sensationalism of the headline or comment.

It is expected that the journey to change attitudes towards mental illness will take some twists.  As I know well from my professional experience the narrative is not a totally simple one.  Mental Illness can have a destructive impact, most often on the individual themselves, but in a small number of cases on those around the person.  Such experiences must be understood and talked about but they do not justify blanket statements and stereotypes which have such a negative impact on people living with mental health problems.

We do not know, nor perhaps will we ever know, exactly what happened on that flight on Tuesday nor what was going through the mind of Andreas Lubitz.  What is certain is that it was a horrific tragedy for the 150 people on board and their families.   Having flown myself last weekend the news struck me all the more forcibly with that sense of the narrow lines of fate which divide the lucky from the unlucky in life.  Flying is still a relatively recent achievement of mankind and there is still a deep seated superstition about it and morbid fascination about accidents which we do not direct to many of the mundane things which claim many more human lives each year.  Despite what it involves flying is a remarkably safe activity.  There will be lessons to learn from this incident but I also wish we would get as excited by motorists using mobile phones when they are driving.

The bold assertion made by some parts of the media is that it was outrageous that Andreas Lubitz, having a history of depression, should have been allowed to fly.  Would the same have been said if he had been suffering from diabetes or another long term condition where, if badly managed, there is a risk of serious consequences?  There are clearly circumstances where someone’s state of health means that they are unfit to carry out their job, especially if that job had the level of responsibility associated with being an airline pilot.  Such judgements should be specific though to individual circumstances not a blanket exclusion of people with a history of a particular condition.

Depression is after all the most common mental health condition.  Worldwide 8-12% of us should expect to experience it in our lifetimes.  There are people with a history of depression in many if not all walks of life.   It is no surprise to find that there are airline pilots who have suffered from it and there is no specific reason why, as a result, they should not be allowed to fly.  It is, in many cases, a very treatable condition.

That is a link to the two final points I wish to make.  Depression is a treatable condition but there is an enormous scandal about access to that treatment with more than 70% of people with the condition unlikely to be offered any form of treatment.  The comparable figure for diabetes is less than 10%.  There is an enormous economic and other consequence of that institutional bias against mental health. That lack of access to treatment  is also probably the biggest single cause of the more than 4,000 lives lost through suicide each in this country.

The second point relates to disclosure.  As I have said, there is insufficient detail to know exactly what happened with Andreas Lubitz.  I have a sense that however that he may not have been in a position to be open about his issues as might have been ideal.  Disclosure is difficult.  While stigma is common and stereotypes abound there are lots of reasons why people feel that they cannot disclose a history of mental health issues.    As I know from personal experience undisclosed issues are much harder to support and make it more difficult to put in place the reasonable adjustments which can make a crucial difference in the working life of someone who is living with a mental health condition such as depression.  Friday’s coverage will have discouraged many more to be open about a history of mental illness.

By the end of the day having seen some of the response on social media and elsewhere I felt more reassured that, while a setback, Friday’s media coverage of this story was not a reversal of the progress which campaigns such as Time to Change have made.  It does show how much is still to be done.

It’s time Cinderella came to the ball

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There are few areas where the health and social care system can make a bigger difference than in supporting young people with mental health and emotional difficulties. On the latest count nearly 10% of children and young people will experience a diagnosable mental health problem and yet we only spend £0.7 billion or 6% of the NHS mental health budget on this area of care. If we get it right in providing young people the help they need we can make a difference to their immediate distress and that of their families. We can also increase the chance that they will successfully complete their education and enter adult life and the world of work with the same chances as their peers. Get it wrong, as I am afraid we in too many cases now, we can condemn some young people to a lifetime of underachievement and with 50% of adult mental health problems developing before the age of 14, trap some people into a history of using of adult mental health services.

For the last 6 months I have been involved in the Children and Young People’s Mental Health Taskforce, whose report is published today. Born in part in response to shocking stories last summer of young people in severe distress having to travel hundreds of miles to access an inpatient bed or even worse being detained in a police station when no beds were available, the Taskforce I hope marks a turning point in the fortunes of this Cinderella of Cinderella services. The news over the weekend that the Taskforce’s report would be accompanied by some financial commitment in the budget has increased my optimism that this may be the case.

Working on the Taskforce revealed a deep commitment and consensus across experts drawn from health, social care and education about what was needed to improve care, and above all outcomes for young people. That view was reinforced by the strong messages from children and young people themselves and from their families about what needed to change.

A number of points stand out.

First the compelling case for investment in an area which has been historically underfunded, has been disinvested in the years of austerity and where the case for the long term benefits of improving access and outcomes for children and young people are compelling. We have known for some time, for instance, that the costs of crime of adult with conduct problems in childhood might be as high as £60 billion per annum and yet we are failing to make the investment in the proven interventions which could make a real difference in the future in reducing that cost.

Second that this area needs the same focus on integration as we are beginning to bring to the care of frail older people. Joint commissioning, which also embraces the money which is spent by schools on supporting young people with mental health problems is crucial if we are to create a system which is up to the task of meeting the needs of children and young people. Joined up provision is also crucial. The role of schools and other universal provision for young people is central. Teachers need training and support to manage the pupils in their care with mental health problems and specialist services in CAMHS should link with schools to provide training, advice and easy routes of referral for those young people whose difficulties need more complex intervention.

Third that the old model of CAMHS, based on the four tiers of response, is no longer fit for purpose. While well intentioned, it has created a system which is over complex and baffling for young people and their families attempting to seek help. I liken it to the experience of a salmon trying to swim upstream against the curent with young people having to fight to show how ill they are to access the necessary help.

Over the last year we have been involved in working at the Tavistock and Portman, together with colleagues from the Anna Freud Centre, to develop a new approach to CAMHS, the Thrive model. Thrive looks to identify not levels of need but rather the purpose of care. By using careful assessment and shared decision making it focuses on helping to distinguish those young people who can be helped with advice and signposting towards self-help resources, those who can benefit from routine treatment and those with more complex needs who need longer term support including those for whom therapy may not deliver immediate benefits but who because of the level of risk they present with still need to be held safely in the system and supported other goals in life. I hope Thrive can play a significant role in improving access and outcomes by facilitating integrated working, working in partnership with young people and their families and making the best use of the specialist clinical resources available and the wider resources which exist in the voluntary sector and elsewhere in the community.

My final point relates to the need for us as a society to stand back and reflect on our wider aspirations for young people. There is no doubt for me that, on the whole, the stresses on young people today are greater than when I was a teenager in the 1970s. The world is less innocent and our expectations on what young people will achieve is greater. There is a need, not just to look at how we respond to the inevitable mental health and emotional difficulties which will emerge, but to focus on resilience; how we equip young people to handle the stress they face and in some cases to change the way we do things to reduce it. Attitudes towards mental health and emotional wellbeing are crucial. My work with Time to Change, and the experience of my own children, convinced me that young people are in many cases more knowledgeable about mental health issues and more sympathetic to those affected than my generation would have been. However there is much to do to build on that and, in particular, to change the attitudes of some of the adults around them whose response is key when those young people experience difficulty.

The Taskforce report and the welcome prospect of a commitment for additional funding are very important step forward but it will be crucial this area is something which any new Government, after May, also makes a priority. Society as whole is the winner if we get children and young people’s mental health right. It’s time Cinderella was invited to the ball.

A voice for Mental Health in London

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London is a special place.  One of the world’s great world’s cities and central to the economy of the UK, Europe and, in some respects, the world.  It is also a city with its own very specific issues  in relation to mental health.

At the end of February the 10 Mental Health Trusts in London came together to launch the Cavendish Square Group as a new voice for mental health in capital.  In doing so we believe there much more we could do, collectively, to raise the profile of mental health as priority in London, advocate on behalf of people who need help and services and celebrate some of the important activities which, whether in the fields of research, clinical services or training and education, are based in the capital.

A city as large, diverse and pressured as London undoubtedly is, will always face specific challenges in relation to mental health.  The risk factors for various forms of mental illness are higher than in other parts of the country.  Research is clear, for instance, that rates of psychosis will be higher in urban areas, in areas large with BME communities which may be experiencing discrimination and poverty or where risk factors such as the consumption of cannabis are particularly prevalent.  London has all these features in spades and this is reflected in the level of demand experienced by London’s mental health services.

The issue of mental health has a wider relevance however for a city such as London.  Mental health and emotional difficulties are crucial barriers to the successful development of the capital’s young people.  Around  1 in 10 of young people in London , or  something like 110,000 individuals, are thought to have a clinically significant mental health problem and the impact of childhood psychiatric disorders cost London’s education system around £200 million each year, in addition to the impact such issues have on the lives and lifetime prospects of the individuals concerned.

Mental health problems are also the biggest single reason for lost productivity in London’s labour force.  This is something which good employers are becoming increasingly aware of and beginning to tackle  but there is much still to do both in terms of providing effective support for people with mental health problems in the workplace and also in reducing the stigma which prevents employees from being willing to disclose problems in the first place.

Finally good mental health is fundamental to the physical health of the capital.  The burdens on the city’s hospitals are significantly increased by the impact of co-morbid mental health issues, whether in terms of the 65,000 Londoners living with dementia or the even greater numbers suffering from depression or anxiety.

All of this makes a strong case for putting mental health and wellbeing at the very centre of the agenda for London’s decision makers, whether the Mayor, local authorities, major employers or health care commissioners and providers.   Our view, however, is that, with some honourable exceptions, there is insufficient priority or interest given to the crucial importance of improving the capital’s mental health.  That’s why as a group of mental health providers we believe we need to work together to champion this issue and help mental health in London have a bigger voice.

As a group, we have set out three ambitions.  First to press for a reduction in the treatment gap for Londoners with mental health problems. Over 900,000 Londoners of working age are likely to experience depression or anxiety yet as many as three quarters of those individuals will fail to get any treatment at all.  The equivalent figure for diabetes is 8%.  Similar stories can be told for many other groups with mental health problems. Despite the rhetoric and some growing political commitment we have an enormous way still to go to deliver anything approximating to parity of esteem between physical and mental health.

Our second ambition is to help make London the most mental health friendly workplace in the world.  Many London employers, including those such as Legal and General operating in the pressured environment of the City, are already recognising this and taking positive initiatives to support employees with mental health problems.  Such employers see mental health friendly policies as offering a competitive advantage in the labour market and many others would benefit by following their example.  There is a role for the Mayor to champion this issue on behalf of London and to work with us and other organisations in London to promote good practice across employers including the public sector and small and medium sized employers.

Our third ambition relates to support the mental health and wellbeing of young people.  50% of adult mental health problems present before the age of 14 and childhood difficulties.  There are many good examples of services children and young peoples’ services in London but there is more to be done to ensure consistency of outcomes across the capital and to ensure a completely integrated approach between the NHS, social services and education.  There is no better investment in the future health and wellbeing of Londoners.

Our final in setting up the group is to stress the opportunity to build on what is already good in London’s mental health provision.  There are gaps to address but the story of London’s mental health is not solely one of deficits.  London already has many outstanding and innovative services and is one of the leading centres for research and education on mental health with organisations such as my own and others which are recognised across the world.

At times mental health has seen itself as Cinderella, the poor relation never invited to the party.  The Cavendish Square Group believes that those times need to change and that London has much to benefit from putting mental health and wellbeing at the centre of its agenda.  Furthermore if the time to come to the ball has come, a decent frock would also help.

Do the small things – St David’s advice for the NHS

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As a Welshman I am proud that we are the only one of the home nations which has managed to produce our own patron saint.  But what do we actually know of the life of Saint David (or Dewi Sant as we call him in Welsh)?

Dewi was a teacher and preacher living in the 6th century.  From West Wales by origins, he ended life as a bishop and was responsible for founding a number of churches and monastic communities across Wales including the one which now bears his name at St David’s.

Dewi came from the ascetic tradition in Welsh life. His monastic code made few allowances for creature comforts, stating that monks should pull the plough themselves without the use of draught animals, should only eat bread with salt and herbs and should spend their evenings in prayer, reading and writing.  He would have made an excellent defence coach for the Welsh rugby team!

According to tradition one of his maxims was “Do the little things in life” (Gwnewch y pethau bychain mewn bywyd). I have always been struck by this sentiment and believe it has a lot to offer in informing the task of improving health and care.

Much is talked about the need for transformation in our health and social care system and the scale of challenges around finance and affordability point to the need for some major changes in how we do things.  However I would argue strongly that the little things should also be central to our focus. Why?

There are a number of reasons.

First because the small things really matter in healthcare. Whether it is relation to the administration of medication, or the taking of a mental health history, small errors in healthcare can literally be life threatening. That responsibility for getting small things consistently right is one the things which makes clinical practice intrinsically challenging and stressful.

The better we get at getting small things right the better our outcomes will be and it should be a key priority for those of us in leadership positions in the NHS to do as much as we can to enable clinical staff to get those small but crucial things right.  As other industries have demonstrated very clearly, IT and real time decision support could have a big role to play in this respect. There is also room for psychologically informed interventions which help clinical staff to disengage from the stress of their roles and reflect constructively on their performance and the care they are giving patients.

The small things are also often the things which matter most to patients and their families.  While we welcome the miracles which can be offered by modern medicine in terms of life saving or life enhancing interventions, we also want to be treated with dignity and compassion when we are unwell and when we are in need of care.  Both of these are not single entities.  They are product of many small acts of welcome, kindness and consideration which repeated consistently reflect the values with which we want to deliver and receive care.

Small things in this way can be representative of bigger attitudes. Nothing better illustrates this point than Kate Granger’s inspiring “#Hellomynameis” campaign. As Kate movingly describes from own experience what chance have we of delivering compassionate care if we cannot take the trouble to introduce ourselves and explain what our role is in providing care. A small act but so symbolic of the value base on which care is built.

Recently when attending A&E with my disabled brother I was struck by the gesture of providing patients and their family with tea and refreshments while they were waiting.  In that instance my brother’s care (fortunately nothing serious in the end) breached the 4 hour wait but the cup of tea was a small and crucial gesture to show that the hospital recognised the value of our time as well as theirs.

Finally the small things matter because that is where we can do best in harnessing the contribution of front line staff for service improvement.  Staff can be justified in holding a sense of cynicism about endless transformation programmes and organisational restructures given the track record that these initiatives have across many parts of the health and social care system.  We need to make sure that these false dawns are not a barrier to engaging staff in making practical improvements in the immediate environment of car where their actions can make a difference.  We should give front line staff the space, tools and responsibility to drive improvements and, while recognising the complexity of the  systems we operate in, we should maximise the scope for local decision making which enables improvements to be implemented and sustained.

This should be mainstream activity but there is no doubt that as systems get put under greater strain and the focus of senior management is constantly directed to firefighting then the capacity of organisations to have an organic focus on improvement is diminished.

So in healthcare St David is right. The small things do matter. And while the challenge of some of the big changes we are going to have to make over the next decade in the delivery of health and social care can appear very daunting the world will always be better a place if we do the small things well.

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