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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.

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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.

 

A Christmas Carol is not just for Christmas

 

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Together with “It’s a Wonderful Life” Charles Dickens’ Christmas Carol is one of the abiding fables of the modern Christmas. I took the opportunity, this year, to reread the original. Written in 1843 this short novel did much to establish Dickens’ reputation. It remains a good and highly relevant read today but I would argue it is about much more than just Christmas.

The central character of “A Christmas Carol”, Ebenezer Scrooge has become synonymous with miserliness and his famous catchphrase “Bah Humbug” the rallying cry for all those who wish to reject the Christmas spirit. However, Scrooge is more complicated than that. More than anything else Scrooge is a man who hates himself and who channels that inner misery into an obsessive pursuit of worldly wealth and a rejection of the needs of others.

During his nocturnal interviews with the ghosts of Christmases Past, Present and Future Scrooge is enabled to confront the causes and consequences of his own misery and moral emptiness. An orphan, rejected by the girl he once loved as a young man, Scrooge has all the hallmarks of someone whose childhood experience makes attachment and empathy difficult.

As he hears again from his former fiancée: “You fear the world too much” she answered gently. “All of your other hopes have merged into the hope of being beyond the chance of its sordid reproach. I have seen your nobler aspirations fall off one by one, until the master-passion, Gain, engrosses you.” Scrooge was not always bad; his own fear and sense of rejection has driven him away from valuing human relationships into an all-consuming focus on financial success. Dickens, always powerful in the psychological description of his characters, captures something very recognisable in his portrait of Scrooge.

As well as the opportunity to reflect on past unhappiness, Scrooge is also moved in his last interview with the Ghost of Christmas Future by the image of his own grave and the unloved and unmourned nature of his death. While we might reject religious doctrines of Heaven and Hell most of us are moved by sense of how we might account for our time on earth. For Scrooge this is the final motivation for him to change his priorities and approach in life.

There is another wider message in “A Christmas Carol”. Dickens was writing in the period in which the impact of modern capitalism was being felt very dramatically across Britain. This was the same decade as the emergence of Chartism, the passage of the first Factory Acts and much other social change. Dickens was a key contemporary figure in highlighting issues around the material poverty and psychological insecurity of those at the bottom of the new society. It is no surprise that Scrooge is, in essence, a money lender and Dickens knew at first hand, from his own father’s experience, the impact of indebtedness.

As well their material impact, Dickens is also good at describing the psychological and social effects of poverty. This is brought out in the struggle of Bob Crachit, Scrooge’s clerk to provide a decent standard of living for his family, in particular given the disability of his son Tiny Tim. Those struggles come together, as they do for many poor families today, in what it is possible to provide for Christmas. Scrooge bitterly captures the reality for many poor families “What’s Christmas time to you but a time for paying bills without money” but for the Crachits Christmas matters.

At the beginning of the story Scrooge has no interest in the poor. When asked to contribute to a Christmas charity he sees the minimalist regime of the Poor Law as a sufficient response. Like many a Daily Mail headline today Scrooge despises those who have been unable to provide for themselves through their own efforts. His resentment of Christmas is that he must pay a day’s wages for no work. His attitude and his introspection are summed up by his line. “It’s enough for a man to understand his own business and not to interfere with other people’s. Mine occupies me constantly.”

By the end Scrooge’s view has changed, in part because of the insight he has received into the reality of the life of the Crachit family. Again, there is a lesson for modern times. Today with poverty again on the rise one of the biggest problems is a lack of engagement between parts of society and a lack of awareness of the reality of poverty. It has become acceptable to stigmatise poverty and to see it, like Scrooge, as none of our business to address. The modern-day stories of poverty, like those of Dickens, are crucial in bridging the gap.

Poverty if not just an issue for Christmas but Dickens understands why Christmas matters as “As a good time: a kind, forgiving, charitable, pleasant time: the only time in the long calendar of the year, when men and women seem by one consent to open their shut-up hearts freely, and to think of people below them as if they were fellow-passengers to the grave, and not another race of creatures bound on other journeys.”

As it is for Ebenezer Scrooge Christmas is a time for us to examine our own priorities and attitudes and see what is in own gift to improve the lives of others. That’s not humbug.

The Heart of the Matter – the Review of the Mental Health Act

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The publication of the Independent Review of the Mental Health Act is a very important moment for mental health in this country.  The report delivered by Simon Wessley, Steve Gilbert and others did not disappoint.  Well researched, well evidenced and well written it got to the heart of how the Act can be made fit for purpose for the 21st century and, just as importantly, of what else needs to change if we are to protect the lives and dignity of people most severely affected by mental illness.

The existence of legislation by which an individual’s liberty can be removed to protect them or, more rarely, others is a unique feature of mental health. There is no comparable provision with physical health.  It is, I believe, a necessary provision, but its necessity makes it all the more important that it is used as sparingly as possible and that when it is exercised it is done so with humanity and compassion and in ways which respect the rights and preferences of individuals whatever level of distress they are in.  This spirit very much informs the recommendations made by the Review.

As in many things in life, context is important. In the last decade we have seen a 40% increase in the number of detentions under the Mental Health Act.  Lots of factors are in play, some perhaps relating to the impact of the provisions of the  Mental Capacity Act but some clearly a consequence of reductions in the number of inpatient beds but more importantly the level of support available in the community for people with severe mental illness.  This is not a surprise and was very much part of the picture identified in the The Abandinned Illness the 2012 report of the Schizophrenia Commission which I was involved in when I was at Rethink Mental Illness.

Showing the welcome willingness to stick to the thoughtful middle ground, the Review is full of sensible and practical recommendations to improve the operation of the Act and improve  the experience of those detained under it.  While defending the principle of the Act the Review deliberately attempts to shift the dial in favour of the rights of service users and families.  I particularly support the emphasis on Advance Choice Documents and strengthening the right of service users to receive timely and properly constituted care plans.  The focus on Advance Choice Documents highlights the reality for many that crisises are a recurrent part of their experience of mental illness and the importance of capturing and respecting insights which may not be available when someone is most distressed and vulnerable. Protecting this with legal rights in the event of the use of Mental Health Act is the right course of action and I am pleased to see that this recommendation has already been accepted.

The recommendation to introduce the concept of a nominated individual rather than the outdated nearest relative is also a positive step forward and one which I have heard much anecdotal evidence over the years to support.  It was good to see in the very moving and powerful letter from the Review’s Service User Panel a strong plea for the contribution and insights of carers and families in supporting to be fully respected.

There are also important recommendations in respect of the boundary between care and custody.  The Review rightly moves against the use of criminal justice settings as  places of safety and to encourage the timely transfer of individuals from prison to hospital.  The corollary of this recommendation is, of course, the need for inadequate NHS provision, both in terms of beds but also the availability of health based places of safety.

The greatest enabler of these recommendations,  as the report rightly recognises, will not be legislative change.  Effective care for those who may need to come under the ambit of the Mental Health Act needs a properly resourced system of support, both in terms of the availability of inpatients beds but also community provision. It is clear to me that, while we have done many other goods things in Metal Health in recent years, core services have become overstretched and there is an urgent need to  adddrss this.  The talk of a target for a 4 hour response time for people in mental health crisis is in essence a welcome response.  The implementation of such a target will need careful thought and a broad approach which puts as much emphasis on the avoidance of crises as it does on the immediate response to ones which occur.  The NHS does respond to targets but we must be mindful that they can also bring unintended consequences.

The final point to make relates to stigma.  On the last occasions  when Mental Health legislation has been reviewed we were in a very different place in respect of public attitudes toward mental illness.  Media coverage was dominated by high profile cases where a person with a mental illness had been the perpretator of violence and wider attitudes were generally pretty negative.  This time things have changed and attitudes are in a much more positive place and that must also shape how we view the urgency and transparency with which we implement these recommendations and make our system of care for those with the most severe mental illness fit for purpose.  In the past being “sectioned” was a matter of shame and stigma for individuals and families.  In 2018 that is no longer acceptable.

 

 

 

 

 

 

 

The eye sees not itself save by reflection in some other thing – why Irish history matters

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For someone who grew up in Birmingham in the 1970s I need little prompting to remember the importance of Irish history. Wherever we end up with Brexit, the question of the Irish border is rightly of huge significance. It has been to the great shame of some protagonists in that debate to be so dismissive of the issue.

However, while I have had a broad acquaintance with Irish history, I have now been struck by how little of the detail I properly understood. On my cycling trip, earlier this autumn, to Ireland I vowed to start to remedy this, and I have just finished Roy Foster’s Modern Ireland 1600-1972, a magisterial overview of the powerful and often tragic course of events which have shaped modern Ireland, and in which has Britain played a leading and often misguided role.

As such, this period of Irish history has three levels of interest for a contemporary British reader. First to understand why the issue of the Irish border really matters in the negotiations about Brexit, second to understand better Britain’s role as colonial power and the consequences this has for the present and finally because, in an interesting way, the story of modern Ireland has something to tell its neighbour about the challenges of striking an independent course in the world.

On the Irish border little has changed since the 1880s when a perceptive commentator observed “It (Northern Ireland) can’t be kept as an England in Ireland without raising a frontier question of the most utterly insoluble character.” We are of course talking not just about a border but a fault line in Irish politics and identity which led to the Partition of Ireland in the 1920s and to a terrible civil conflict for twenty years in my own lifetime.

The issues this split in identity caused, have lasted well over a century and have engaged and, eventually defeated, some of the greatest political leaders of this country including both Gladstone and Lloyd George. That is why the Good Friday Agreement of 1998, which has brought twenty years of peace to Ireland (and to Britain), is such a significant political achievement. A key part of its impact is grounded in the concept of an open border between two states which are both part of the European Union. Ideology over Brexit must not be allowed to compromise this achievement.

My second theme relates to Britain’s history as a colonial power in Ireland. While there are challenges for us as a nation in confronting our previous actions as colonial power in many parts of the world, there are few stories more difficult than that of Ireland. Ireland was one of England’s first colonial adventures. Its early conquest was uncertain, and at times brutal, and from 16th century the issue of religion further complicated the picture. British influence often alternated between the malign and indifferent and by the time British politicians engaged in a more constructive way with the Irish question, the opportunity to resolve issues peacefully had in some ways past.

The Irish Famine of the 1840s, while highlighted in Foster’s account as less of a singularity than sometimes supposed (there were 14 complete or partial famines between 1816 and 1842), epitomises that watershed in the relations between Britain and Ireland. Following the Famine and the mass emigration which it encouraged, the population of Ireland fell between 1841 and 1911 from 8.2m to 4.4m in 1911, making Ireland the only country in the world whose population in 1820 was larger than that of today. While there was some attempt by the British Government, led by Robert Peel, a decent man who did have some understanding of Ireland, having served previously as Chief Secretary to Ireland, it was not enough. In any case it could not address the underlying injustices around land ownership which were fundamental in making the country so vulnerable to the arrival of the potato blight, phytophtora infestans. This episode in the shared history of Ireland and Britain should be a standard part of the history learnt in British schools.

Thirdly there are some interesting lessons from the history of Ireland since the independence of the 26 counties in the 1920s. The journey since the creation of the Free State in 1922 has not been straightforward. The Irish Civil War of 1922-3, which set those who had accepted the compromises of the 1921 Treaty against those who maintained a more fundamental vision of independence from Britain, cast a long shadow. While Ireland secured independence of action that came at the expense of economic hardship with the new Free State struggling, for instance, to maintain the level of welfare benefits such as pensions introduced by the British Government. Finally, for many decades a change in political relations failed to end Ireland’s dependent relationship with its larger neighbour. All of these facts seem rather relevant to Britain, itself, in contemplating a post Brexit world.

Britain and Ireland have an enormous amount of shared history and it strikes me that, on this side of the Irish Sea, we should give a much greater focus to understanding what has happened in Ireland and our own part in those events. As the quote from Shakespeare’s Julius Caesar which forms the title of this blog it is in reflection from others that we have the most to learn about ourselves. Britain as a country has never more needed that insight.

The war which should have ended all wars

 

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There is something very portentous about the anniversary of the Armistice which ended the Great War at the eleventh hour of the eleventh day of the eleventh month, a hundred years ago  in 1918. Few wars have been as much remembered and it is the First World War which has given us the modern rituals of remembrance: the poppy, the cenotaph, the two minute silence, the war memorial and Remembrance Day itself. There is much to remember and the aim of this blog is to provide some arguments for why.

I have always been interested in the Great War, partly because it is big history, partly because it was a major historical event which, through a number of family members, I had a direct connection.  Over the last couple of years I have been able to extend my reading and gain some fresh insights into the conflict.

There were and still are various narratives about the War and what it achieved. Some see it as a pointless loss of young life, others make a case for the importance of of their issues over which the war was fought and the consequences that might have happened if Britain and other nations hadn’t gone to war.

As ever the reality is more complex but I want to discuss a number of historical lessons which all have significance today.

This starts with the  mass hysteria which carried Europe to war in 1914. Much is made in discussing the start of the War about diplomatic failings and the inflexibility of railway timetables. Those things are important but what strikes me more than anything about the events of 1914 is a sense that the people of Europe and, in particular, its young men wanted to go to war. Accounts and images (including the famous one from Munich which captures the face of the young Adolf Hitler) from all over Europe show almost a sense of relief at the coming of conflict and a nostalgic revelry in the idea of young men leaving the drab reality of industrial or bureaucratic drudgery to return to the heroic world of being a soldier.  It strikes me that with that groundswell of public opinion there was little politicians could do to argue against the idea of going to war.

There has been something of the same sense of hysteria in some contemporary developments here and in the US. Such developments are hard to check but they need brave people to speak up against them and they need politicians prepared to try to contain them rather than stoke them for their own political ends.

The First World War was also characterised by a fundamental shift in the nature of war. Despite the precedents set 50 years earlier in the American Cicil War the nature of the conflict unleashed in 1914 seemed to have taken most generals and politicians by surprise. The adage that it will all be over by Christmas was widespread and, in Britain, Kitchener was a fairly lone voice in seeing the inevitability of a long conflict with the resulting need for a massive military recruitment. Throughout the war despite the reality of the trenches Generals continued to hanker after the use of cavalry.

The mechanisation of warfare was at the heart of this with its resulting massive destructive power and merciless greed for human life. In the Napoleonic Wars 10 lives were lost in every hour of the fighting. This had risen to 230 in the Great War.

Yet despite this it was a war where the behaviour of most generals (there were exceptions such as Petain in France) was marked by optimism bias. While tactics did evolve through the War Generals such as Douglas Haig committed time after time to a belief in the “Great Push” and the ability of human courage to prevail over barbed wire, heavily fortified positions and murderous machine gun fire.

This links to the influence of lived experience. For soldiers such as Siegfried Sassoon there was an unbearable distance between the experiences of soldiers at the Front and the opinions of those driving the War at home. Although the First World War was, at the time, the most photographed conflict in history and pioneered new approaches such as Geoffrey Malins’ filming of the explosion of the mine at Beaumont Hamel on the first day of the Battle of the Somme, this was a different age and news from the Front was still heavily censored.

We now have the graphic accounts of the war poets and hundreds of others who entrusted their experiences of the battlefields to writing. What if some of those accounts had been widely available in real time?

The final reflection rests on the need to win the Peace. We now know, with hindsight, the way in which the humiliation of 1918 and the harshness of the Versailles Treaty contributed to the Second World War less than a generation later.  The failure of the League of Nations is also a grim reminder to us of what might happen when nations withdraw from the institutions and spirit of international collaboration.

In many ways World War One should have been the war to end all wars. It wasn’t but it is important we don’t let its remembrance pass without reflecting as deeply as we can on which of its lessons we can most draw on in looking at the challenges of our own age.

On the centenary of Armistice Day we rightly remember the sacrifice of those who gave their lives in conflict. However let’s also remember those things which are most likely to prevent conflict in the future.

 

 

 

Anthems to doomed youth

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This Sunday (4th November) it is 100 years since the death of Wilfred Owen, perhaps the most brilliant of that group of soldiers who committed to poetry their experiences of the First World War.

Owen died but a week before the ending of hostilities in a brave attack on the Sambre-Oise canal. There are no eye witness accounts of his death and he is buried in the corner of the cemetery at Ors.   In the intervening century he has become the embodiment of First World War poetry and many more British schoolchildren will be familiar with his poem “Dulce et Decorum est” than would be with the Latin quotation from Horace after which the poem is named and which was staple fare for pupils of Owen’s own generation.

Owen, while the most familiar name, was one of many outstanding poets from this generation of doomed youth. Some like Owen, Siegfried Sassoon and Robert Graves knew each other and encouraged each others’ work.    They came from many different backgrounds but lived in an era where poetry had an acknowledged currency as a mode of expression.  Few, perhaps with the exception of Rupert Brooks, author of the famous line “That there’s a corner of some foreign field which is forever England” acquired fame at the time but they now define our understanding of the Great War.

I’ver been familiar with First World War poetry since my own schooldays but in recent years have had the chance to broaden my reading. When I toured the Western Front on my bike in 2016, I included a volume of First World War poetry in my luggage as a psychological guide to the landscape I was about to visit.

So what is the essence of First World War poetry and why is it so special? I wanted to share in this blog a few thoughts.

The first objective of many of the poems is to give expression to some of the intense experiences and feelings which the poets were going or had gone through.  While there is some wonderful prose writing from the period, it takes the intensity of poetry and its language and imagery to do justice to some of what soldiers in the trenchs were going through.

Take Owen’s own description of a gas attack in “Dulce et Decorum est”:

Gas! GAS! Quick, boys! – an ecstasy of fumbling

Fitting the clumsy helmets just in time,

But someone still was yelling out and stumbling

And flound’ring like a man in fire or lime

Some of the urge to write is also an attempt to process unbearable feelings and it is striking that a number of  War Poets, including Owen, were treated for shell shock. In one case, that of the Gloucestershire poet, Ivor Gurney, the war left a lifelong history of mental illness.

The second feature of War Poetry is to portray a realistic view of the war, in contrast to that portrayed through the newspapers or official communications. It is that spirit in the poems which has often most captured the imagination of readers. For the most part the soldier poets were not pacificists. They fought as bravely as anyone and many such as Owen, Edward Thomas and the Welsh poet Hedd Wyn were killed in the fighting, often avoiding the opportunity for the chance  to escape the front line by taking on, for instance, a training assignment. This perspective is summed up by Edward Thomas’ poem “This is no case of petty right or wrong” which, while rejecting jingoism, is filled with a deep sense of patriotism, grounded in Thomas’ love of the English (and Welsh) countryside and life.

By contrast there is hardly a word, in any of the poetry I have read, of hatred for the enemy. Indeed in a number of poems there is a recognition that the horrific experience of the War is something which soldiers on both sides are experiencing.  There is lovely poem by Ivor Gurney “Serenade” which captures the moment when the sound of Schubert on a gramophone in the German trenches connects the two sides for a minute. More hauntingly, Owen’s poem “Strange Meeting” describes the tormenting image of a German soldier whose life he, himself, has taken.

Some of the most moving poems are those which mark the intense bonds between fellow soldiers, including the feelings which officers will have for the men under their charge.  Nowhere is this captured more intensely than “In Memoriam Private D Sutherland” by EA Mackintosh which so poignantly marks the deaths of the young men in his command as if the poet was a second father to them.

You were only David’s father

But I had fifty sons

When we went up in the evening

Under the arch of the guns

And we came back at twilight –

O God! I heard them call

To me for help and pity

That could not help at all.

It was Horace again who pointed to his poetry as his everlasting monument.  Little could be more true of the poetry of the First World War and the amazing descriptions they have left of one of the most horrific conflicts in human history.