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Mental Health – The State of Care

CQC

I have just finished reading the very good report produced by the Care Quality Commission (CQC) on the lessons they have drawn from the first round of comprehensive inspections of mental health providers.  Although they may be subject to criticism from time I am a strong supporter of their role in underpinning high quality care and have written about this previously in this blog.  This report is both fair in its assessment of our sector but also challenging about what still needs to be done to deliver the kind of services which people with mental health problems deserve to receive.  It provides a good reference point for my own reflections on the state of care and on the priorities for action.

There is much in the report that mental health providers can take pride in with 74% of core services provided by the NHS and 76% of those provided by the independent sector rated as good or outstanding. This achievement is explicitly acknowledged has having been made against a backdrop of a rise in the quantity and complexity of demand, a product both of positive factors such as the raising of stigma as well as less positive factors such as the reductions in social and community support which have made it harder for people to stay well in the community.  Best of all virtually every service was rated good or outstanding for having caring and compassionate staff.

There is much which those of us working in and leading mental health providers can take pride in but there are also important challenges. In this blog I would like to focus on three.

The first and most significant of these relate to the pressures on the workforce. CQC’s report highlights a 12% fall in the number of mental health nurses between 2010 and 2017 and at present we seem to be losing staff more quickly than we can train them. Health Education England’s recently published Mental Health Workforce Plan makes the scale of challenge even clearer and we need urgent and converted action to address significant gaps in the mental health workforce which would be required to deliver both current services and the new developments set out in the Mental Health Five Year Forward View.  In doing so we are also need to pay attention not just to numbers but also, crucially, to the quality of experience of people working in mental health services.  Compassion and empathy do not grow in a vacuum and we need to be mindful of the intrinsically stressful nature of mental health work.  Systematic investment in good quality supervision and wider initiatives to staff resilience will be crucial and essential if we are to stem a worryingly high level of staff burnout and turnover.

The second issue relates to our ability to deliver, at a time of severe financial pressure, core quality services alongside the new developments set out in the Five Year Forward View. I believe some progress has been made in stemming a tide of disinvestment in mental health services and I strongly support initiatives to promote greater transparency about CCG and other spending.  There needs to be some realism however about the challenge of the task ahead especially where the investment for new developments is predicated on making cashable savings in other parts of the system.  New service developments, welcome though they are, must not come at the expense, either in terms of money or management focus, of the worsening of existing services.  Similarly in area of care where the level of unmet need is so high must we be seduced by overoptimistic assumptions about our ability to manage demand with the danger that we improve access for one group of people with mental health problems at the expense of another.

The third issue relates to inpatient care. As the CQC report highlights this is the part of the system under most pressure and where the incidence of issues around quality is most common.   Every conversation I have ever had on the subject with people who have experienced serious mental health problems, highlights the importance of good quality inpatient care when they need it.  There is no answer to what the right number of beds is for any given area but, again, as the CQC report highlights we have a relatively low level of provision compared to other developed countries and those beds are increasingly full of individuals detained under the Mental Health Act.  The experience we do have suggests that a low level of inpatient provision can work where there is corresponding high levels of investment in community based home treatment services and alternatives to admission such as Crisis Cafes or Recovery Houses.  The quality and skill mix of inpatient provision also matters with evidence that there is a clear correlation between services with a richer skill mix including a strong psychology input and lower lengths of stay.  Many parts of the country will be grappling with these issues as part of their STP plans and it will be crucial this gets the right level of focus if the system is to be capable of managing a continuing growth in demand.  The plans to shift commissioning responsibility for secure and Tier 4 CAMHS services to local level also provides opportunities to shift the balance of care and strengthen the infrastructure of community services.

These are tough times for everyone working in public services. AS CQC’s report highlights the mental health sector has been remarkably resilient given the pressures it has faced.  The challenge to sustain this and deliver the new ambitions set out in the 5 Year Forward View for Mental Health will require strong leadership combined with honesty about what can be delivered within the real resources which are available.  There is some ground for optimism but a hell of a long way to go.

 

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Finlandia

DSC_3224It’s always special to visit a new country and it was a particular delight to spend two weeks in Finland this summer. In some ways a place which, over the years and thanks to music and sport, has felt familiar and yet one which, as my trip reminded me, I knew very little about.

The first historical reference to the inhabitants of Finland (Fenni) occurs in the Roman historian Tacitus’s Germania. It’s not particularly flattering.

“There exists amongst the Fenni a remarkable savagery and detestable poverty. They have no arms, no horses, no fixed abodes, eat grass for food, wear skins for clothes, sleep on the ground.”

Finland has come a long way since then but the quote is a reminder that this is a country which has had to build itself in a land where climate and terrain are often inhospitable and where a harsh poverty has been a reality for much of its history.

In a fortnight we only had a taste of things but one cannot but be impressed by the stunning beauty of Finland’s landscape. We spent some time both by the coast and in the Finnish Lake District (Finland has more than 187,800 lakes of more than 500m2).  In both there is a wonderful sense of emptiness and wilderness as if mankind had still only made a tiny scratch on the surface of this pristine countryside.

Forest is the other striking feature in Finland and, in particular, the distinctive melange of pines and silver birches. As readers of this blog will know I have a thing about trees and there was something about tall Finnish silver birches waving in the wind which was one of the most distinctive images of the holiday.  All of this was made all the more special by the long, soft light of a northern summer.

Towns were, on the whole, less impressive. Given Finland’s history many are relatively modern with an American style spread of undistinguished architecture.  However there are honourable exceptions and Helsinki, in particular, is an immensely elegant city, surrounded by sea and with some really stunning buildings such as its Lutheran and Orthodox cathedrals.

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That provides a nice link to Finland’s history and people. As an independent country Finland is 100 years old this year having secured its independence from Russia, the second of its foreign overlords (the first was Sweden), in the wake of the Bolshevik revolution.  The proximity to Russia is a striking feature of the country.  It made me look twice to see St Petersburg on the signposts on Finnish motorways or Moscow as a destination on the departure board of Helsinki’s lovely art deco central railway station.  During the 20th century Finland’s history was very much dominated by its big eastern neighbour, fighting two wars against the USSR, the latter alongside the Germans, during the 1940s and maintaining a difficult co-habitation during the Cold War while being part of the western bloc, a policy summed up cleverly in our guide book as “bowing to the East while not mooning to the West.”  Since the fall of communism Finland has shifted its focus more to the West but retains its own distinctive and progressive identity with some impressive achievements, both economically and in areas such as education.

The Swedish connection remains important. Finland was part of the Swedish kingdom from the Middle Ages to the Napoleonic Wars and for a long time Swedish was the dominant language of the elite. As I am familiar with from a Welsh background, the issue of language was very central to the emergence of Finnish nationalism in the 19th century  but Swedish speakers remain an important, if much smaller, linguistic  minority, in particular in the South of the country where road signs are mostly still bi-lingual.

Finnish is well known as non-Indo-European language. I made an effort to try to learn some basics before I went but it is extremely difficult and I was only able to put my knowledge to use on a handful of occasions, in part because the Finns all seem to be able to speak English, in many cases to a very high standard.

Linguistic skills were one of many ways which make Finland an easy place to visit.  The Finnish are usually quiet and undemonstrative but always helpful and this was one of the countries I have visited in which I have felt most welcome.  That welcome was epitomised when I was struggling to work out the Finnish system of paying for petrol upfront before filling your tank.  While I was fumbling around trying to work out what to do with the pump a local came over to enlighten me. Anywhere else that might have happened with either a sense of condescension about a stupid foreigner or a missed placed sense of pride in the local way of doing things.  In Finland it was neither, it was just helpful.

A final word on this blog goes on two Finnish cultural icons who, in part, inspired our trip. My wife, like many, was a childhood fan of the Moomintroll stories and we visited, last week, the Pellinki Islands off the southern coast of Finland where Tove Jansson, their creator and also talented painter and writer of adult fiction spent summers throughout her life.  Her writing shows a profound sense of understanding of the minds and preoccupations of children and is also deeply inspired by the Finnish landscape.

Since I was first introduced to it while at University, I have had a love of the music of Jean Sibelius. It is deeply associated with the emergence of Finland as a nation but also draws from the sights and sounds of the Finnish countryside.  Visiting Ainola Sibelius’s home and resting place north of Helsinki was a moving experience as was blasting out Sibelius’s symphonies on the car CD as we drove through across the countryside which inspired them.

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So I would definitely recommend Finland as a destination for a visit. If you don’t want to take my word just listen to the third movement of Sibelius’ 5th Symphony.

 

Poverty should not always be with us

Depression 

In the last month I have taken up a new responsibility as a Trustee of the Joseph Rowntree Foundation. It’s an organisation I have long admired and I am delighted to have the chance of being part of its mission to tackle UK poverty.

The Joseph Rowntree organisations have been working in this field for well over a century. What we mean by poverty in 2017 is, in some ways, very different from when those organisations started their work in the first decade of the 20th century.  However despite undoubted progress on some fronts, poverty remains a scourge on the face of British society which continues to call for action.

I have three drivers for wanting to focus on this issues. The first is personal.  I am very lucky to have enjoyed many advantages in life, in my upbringing, my education and the options which have been open to me in my professional life. It is not so long, however, since, particularly my father’s family in South Wales, experienced poverty in the wake of mass unemployment in the 1930s. The narrative of that experience was crucial in forming my values as a young person and in setting a belief that a key goal of social policy should be to eliminate both the material and psychological distress engendered by poverty.

The second driver is a reflection from 30 years working in health and care is to what a large extent poverty drives not just material disadvantage but a wider range of other life outcomes: poorer health, poorer education, poorer work, poorer housing and poorer participation.  Poverty stacks the odds against individuals and communities across a range of issues.  Tackling poverty is key to addressing so many other social problems.

The final motivator comes from my particular professional experience in the ten years I have worked in the field of mental health. There is a strong relationship of cause and effect between mental ill health and poverty.  Poverty and social disadvantage are for many a consequence of mental ill health in large part due to the impact mental illness has on a person’s chance of getting or keeping a job.    At the same time the chances of developing a mental illness are much higher amongst higher amongst people and families in poverty with the psychological impact of poverty being a significant risk factor for mental health problems.

The shape of poverty does not stay still. Some laudable progress has been made in recent decades in reducing child and pensioner poverty but, sadly, other issues have come to the fore.  A number of challenges stand out.

There is a troubling concern about the growth of the working poor and the inability of large number of people, despite the introduction of minimum and living wages, to sustain a decent quality of life while in work. There are many issues behind this, some relate to issues around costs, such as housing, as well as to problems with income.  These problems have got significantly worse with the restraints on wage growth since the last Recession and are further exacerbated by the increase in inflationary pressures since Brexit.

It is also a great worry to see a growth in the concentration of poverty in families affected by disability. While much progress has been made in promoting the better participation of people with disabilities in the labour market there is clearly still a major issue for individuals themselves and for carers.  Some of the issues are clearly reinforcing.  If you are already in poverty and have a disability or a caring responsibility there is a double level of disadvantage.  Benefit reform has been particularly punitive on people with disabilities.

Tackling poverty has, in my view, three requirements. The first is to make poverty visible.  JRF has done an excellent job over the years in marshalling the evidence and data on the nature and causes of poverty in the UK.  As well as the facts there is a need for human stories, what poverty means on a day to day basis for the people who live with it.  Those stories have been so crucial for changing opinion in other causes such as attitudes on mental health.

The second is to build and develop the evidence base for what works and supporting those who wish to use that evidence base in practice.  Action is needed at many different levels but as in many areas of public policy there seems to be a particular opportunity to look at interventions which are place based and which bring together the contribution of different agencies.

The final ingredient is helping to create the political will for change. Poverty should be something which is seen by public and politicians as intolerable in our society.  Sadly. however, it is often too easily tolerated, in part because it is invisible, in part because it is convenient to blame people in poverty themselves for the circumstances they find themselves in, in part because it feels too difficult to do anything about it.   None of these are a good enough excuse.  Campaigning for change needs to be a matter of head and heart.  Research and evidence create the case for change and promote solutions.  However time and time again it is an emotional reaction to an event such as Grenfell Tower, or to the sight of people sleeping on the street or forced to use food banks which creates the real momentum for change.  Participation is also crucial.  People in poverty, for a variety of reasons, are some of the most excluded from the democratic process.  Politics is a numbers game and as we’ve seen very clearly with the youth vote, democratic participation can have a positive effect on political agendas.

Back to my South Welsh roots. In the 1930s The Prince of Wales, the future Edward VIII, visited the South Welsh valleys and saw at first hand the impact of poverty and mass unemployment.  He was moved by what he saw and famously commented “something must be done.”  We need the same revelation in our leaders in respect of poverty in 2017.  We can all be part of making the case.

 

Remember, Remember 1st July

101 years ago today thousands of British soldiers stood prepared to climb out of their trenches and take part in what was hoped to be a decisive attack on the German lines in front of them. Within minutes of the start of the attack many lay killed or injured in what remains, and I hope will always remain, the bloodiest day in British military history.  Of 116,000 British and Empire troops who took part in the battle on 1st July 1916, 57,470 became casualties and 19,240 were killed.

Last year, as part of my Western Front cycle, I spent a couple of days on the Somme battlefield.   The saddle of a bike provided an excellent viewpoint to appreciate the landscape in which so many brave young men were sent to their deaths.  I have also just finished reading Jolyon Fenwick’s excellent “Zero Hour” which describes the story of that day and the countryside in which it was fought with the help of a series of maps, contemporary accounts and panorama pictures from the front line positions from which the attacks were launched.

In only two parts of the front: Mametz and Montauban were the British successful in holding at the end of the day the positions they had set out at the beginning of the day to capture.  Elsewhere the attacks either failed at the outset, driven back by the intensity of the German machine gun and shell fire, or hard won gains had to be abandoned later in the day when the original attackers became overwhelmed and attempts to reinforce new positions were given up.

The underlying story of the day was similar across the front. Generals had been hopelessly optimistic about what the attack might achieve.  The British bombardment, while full of “shock and awe” for those witnessed it was of insufficient intensity to deliver a knockout blow to the German defensive positions which, in any case, were deeper and more extensive than anticipated.  Finally the timing of the British assaults gave the German defenders in many cases a crucial period of time to emerge from their positions and set up a deadly network of machine guns.  As a result in many sectors of the front the British troops emerged from their trenches into a sea of bullets.  In this context the attackers didn’t stand a chance and many were killed before they had even got out of their trenches.  It took months to retrieve the bodies of those who fell and for some no identifiable physical remains were ever found.

The day was full of the most incredible courage. Perhaps nothing epitomises this more than the attack of the Ulster regiments on the Schwaben Redoubt, the strongly fortified German position near Thiepval.  With an element of surprise and through immense bravery they managed to capture the position and open up the genuine possibility of a breakthrough.  However, as was the case elsewhere, it was not possible to reinforce the position and by 10pm it had had to be given up.  A moving memorial marks the position today.

Some of the poignancy of this day related to the nature of the army which took part in it. This was the outing of Kitchener’s New Army, the thousands of young men who had left civilian life at the beginning of the War to meet the call to serve King and Country, driven by both by patriotism and by the wish to escape the mundaneness of everyday life.  The army was full of Pals Regiments; new units recruited from the same place, young men who had joined up at the same time, often encouraged by employers or civic leaders.  Much of the idealism which had brought those young men together was challenged to its roots on that first day of the Somme although what remained was a deep commitment to those sharing that common experience.

News of the conflict in the First World War was heavily censored. “Forward in the West” was the first headline in the Times.  However the news of the scale of the loss could not be kept hidden for ever.  Too many families were affected and news trickled back through and formal and informal channels about those who had survived and those who had lost their lives.  This was one of the first battles in history with some official filming of the action.  Geoffrey Malins film The Battle of the Somme, which included footage of the explosion of the massive mine at Beaumont Hamel, was seen by over a million people.  It opened up some of the reality of modern warfare to the civilian population and established a tradition of battlefield coverage which we now take for granted.

To finish some comment is necessary on the conduct of the Generals and the part they played in such a calamitous loss of life. The First World War brought enormous challenges in effective battlefield leadership, in particular given the absence of voice command, which before and after would allow Generals to direct operations in real time.  In essence once started the Generals were fairly powerless to alter the course of events.  However they could control the strategy and preparations and serious mistakes were made in overestimating the power of the British artillery and underestimating the remaining strength of the German positions.  Most galling was the naïve optimism of some, not all, commanders and the apparent willingness to tolerate such enormous casualties for such small gains in territory or strategic advantage.  The tone was set from the top and Douglas Haig’s comment when notified that casualties for the day had reached 40,000 “This cannot be considered severe in view of the numbers engaged, and the length of the front attacked” illustrates a contempt for the value of individual life which was repeated across military leaders in the conflict.  As we have a taste of today there is something deeply dangerous when such a gap grows up between those leading and those led and where false certainty is imposed on situations where none can legitimately exist.

We may be past the centenary now but the anniversary of the first day of the Battle of Somme should be a constant reminder of the horror and futility of war. For many years I sat each Sunday in church near the memorial to Frederick William Wood, son of the vicar of Headingly and member of the Leeds Pals.  The same age as my grandfather he was one of those 19,000 British soldiers who died on that day.  There are days in history we should never forget.  1st July 1916 should be one of them.

Who cares for the carers?

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It was timely and appropriate to hear at last week’s NHS Confederation Conference from staff involved in the immediate response to last month’s bomb attack in Manchester. The stories of the commitment of NHS staff in responding to the needs of those were affected by the blast were truly inspiring.  It was also important to reflect on the psychological and emotional strains which such events place on staff and to recognise what we need to do support them.

However I was also struck that this story was not one just about exceptional events such as the Manchester bombing, but had much greater significance in reminding us about the underlying nature of clinical work and how we address what is needed to promote staff wellbeing and resilience.

We have two reasons for needing to do so. First the values of the NHS should reinforce in us a strong commitment to looking after our staff, as we always say our most valuable resource and one which is doing, day in day out, a difficult and psychologically challenging job.  The work of clinicians and others who are involved in directly supporting patients work in constant proximity to distress, suffering and death.  Inevitably this has an emotional cost, particularly when combined with the sense of responsibility which staff will feel about the impact of their own actions on what happens to patients. We need to recognise this much more explicitly in our public discourse about the delivery of healthcare.  We are not making widgets.

The second reason, is, as researchers like Michael West have clearly demonstrated, that there is a close correlation between staff engagement and wellbeing and the quality and effectiveness of care. His analysis of the results of the staff survey shows clearly that Trusts with better scores for staff engagement also do better in relation to patient satisfaction and for certain measures of clinical quality.  Poor engagement correlates with burn out and we should all be concerned at the finding in the latest staff survey that 37% of staff report having taken a period of absence in the last 12 months due to work related stress.

These issues matter all the more in the context of the very significant pressures we face on workforce and staffing. Whatever our efforts the pipeline for new supply of clinical staff will not address easily the likely gaps we will face across a range of clinical disciplines over the next 5 years, gaps which Brexit and other factors are only likely to worse. Initiatives around retention will be key if we are to find a way through.

Pay will be a key issue and I welcomed the suggestion made by the Secretary of State at the conference to argue the case for lifting pay restraint for NHS staff. The worsening differential between NHS staff and workers in other parts of the economy must be a serious concern and without some attempt to address this, our workforce problems will only get worse.  It goes to say, of course, that any increase must be fully funded and not add to the financial problems of providers.

However alongside pay we must also prioritise the agenda of staff wellbeing. The question of the psychological dynamics of clinical work has long been an area of interest for my Trust.  This starts, as I highlighted earlier, with a recognition of the psychological and emotional wear and tear of caring roles and the need to invest in approaches which help staff feel supported.

Michael West sees good engagement underpinned by two ingredients: job resources such as the degree of control staff feel over their work, systems of reward and recognition and the extent to which staff supported by their organisation and personal resources around individual’s resilience and ability to process stress and distress.

There is a long established tradition of work discussion groups which provide a safe, confidential, multidisciplinary and non-hierarchical forums for staff to come together and deal with the issues they encounter in their day to day clinical practice. A number of models exist, Schwartz Rounds and Balint Groups being amongst the most well-known and there is a good body of knowledge about how they support staff wellbeing and engagement.

At the heart of both approaches is the issue of empathy and compassion, the ingredients which above all others distinguish excellent care. The ability, in the words of Ken Schwartz, whose legacy led to the creation of Schwartz rounds, to deliver the small acts of kindness which make the unbearable, bearable for patients and their families. Such approaches are followed in many NHS organisations but should, I would argue, become mainstream.

At a time when our NHS faces unprecedented demands what is, in the scheme of things, relatively modest investment in protecting the wellbeing and engagement of our staff must be a top priority for leaders. Without them we have little chance of meeting the challenges ahead.

 

A follower of things historical

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My love of history started very young with the Ladybird book of Julius Caesar and Roman Britain. It has been a lifelong pursuit, the subject I studied at university and a major source of ongoing interest ever since.  Furthermore, it has been, I would argue an immensely practical training for the career I have pursued.  For how can one plan for the future without what, and just as importantly, why and how things happened in the past?

History, our ability to develop a collective understanding of who we are as individuals and groups and how we have been shaped by what has happened to us is at the heart of what makes us human. It is a crucial intellectual discipline in itself but also a critical part of understanding many other issues, medicine and healthcare to give but one example.

History operates at two levels. The first is the process of research: the discovery and analysis of records and other sources of evidence; the sifting of truth from falsehood; the piecing together of a story from disparate facts.  Historical periods come in two varieties.  Those like the ones I studied at University where sources and data are thin on the ground and where the process of reconstruction can, at the best, be only partial.  Those like our own times where there is too much information and the challenge is to spot the wood for the trees.

The other level of history is broader and more strategic. The task here is to draw together evidence to construct a wider narrative about what has happened in the past and what it means for us in the present.  This can involve, at times, opening up new aspects of inquiry or recasting the traditional interpretations of events or bringing new models of thinking to the task of how we look at the past.

All subjects are, in their own way, ideological but history is explicitly so. George Orwell’s adage that “He who controls the past controls the future” is highly relevant and has often been at the heart of the motivations of those who have written or commissioned history.  Ideological bias has always to recognised but, I would argue, it has not always been a bad thing.  Marxist historians have brought many prejudices to the history they have written but they have also been responsible for a healthy willingness to broaden the focus of historical enquiry away from the rich and powerful to include the lives of ordinary people.

To finish this blog I wanted to share six of the historians whose work I have most appreciated. It was hard to stop at six but here goes.

My first choice has to be the Greek historian Thucydides whose account of the “History of the Peloponnese War” is one of the first pieces of serious historical writing which attempts to describe events and their causes. It remains gripping history two and a half millennia later.   The description of Pericles’ famous Funeral Oration provides a fascinating and powerful insight into the values and tensions of the first democratic society.

My second historian is Eric Hobsbawn whose four volume of the rise of industrial capitalism and modern society in the two centuries between 1789 and 1989 is monumental in the sweep and depth of its historical perspective. The last volume “The Age of Extremes” is a fascinating account of the last century, the scale of change in human life it entailed and the brutality it unleashed as part of those changes.

Third up is Roy Porter, originally a historian of the 18th century but one whose reputation is based on his work in describing the history of medicine and significantly that of mental illness.  His landmark book “The Greatest Benefit to Mankind” is a fascinating account of the history of medicine, both in terms of the tracking the scientific progress made by medicine but also the also the social role and motivations of those who have practiced medicine.  His extensive writings on mental illness are well worth reading, in particular for its determination to create a place for the lost voices of those who have been affected by mental illness in the past.

My next choice is the American historian Barbara Tuchman, one of the best historical narrators I have come across, whether in “August 1914”, her brilliant account of the first month of World War 1, “A Distant Mirror” an account of the 14th century and the Hundred Years’ War through the lens of the life of the French nobleman Enguerrand de Coucy of “The March of Folly”, a set of essays which prove Voltaire’s dictum “History does not repeat itself, men do.”

“Montaillou”, by the French historian Emmanuel le Roy La Durie remains one of the most fascinating historical bookds I have ever read. Due to the survival of the amazingly detailed records of the Inquisition, La Durie is able to reconstruct, in microscopic detail, the life and beliefs of a 13th century village in the Pyrenees which is gripped by the Cathar heresy. Such an insight into the daily lives, let alone thoughts and beliefs of past generations is rarely possible.  The past is indeed “a foreign country”.

It would not be unsurprising for me to finish with a Welsh historian, John Davies. His “Hanes Cymru”, written in Welsh but available also in England provides the best and most integrated account of the history of my own nation.  As this blog has tried to argue, history is essential to all sense of identity, particularly the identity of nations, however small.

Others will have their choices but all the six I have chosen I value not just for what they have to say about the past but what they can contribute to an understanding of the present.

We live in an uncertain times and that makes history, for me, an ever more essential area of study. For if we do not know where we have come from, how can we judge where we are going?

 

 

 

 

No alternative – next steps on the Five Year Forward View

NHS Building 

The refresh of the Five Year Forward View, published on Friday, gave all of us in the NHS our marching orders for the priorities in navigating the next two crucial years in the service’s history. The original 5 Year Forward View was one of those rare genuinely strategic moments, inevitably Friday’s publication was tactics.  Like most of the key pronouncements in the Stevens’ era it was worth reading and, in my view, made the most of a difficult hand.

The abiding message was more of the same and quite right too. The original Five Year Forward View prompted an unprecedented level of consensus on what needed to change if we were to deliver a sustainable health and care system which could withstand the demographic and other pressure of the next 20 years.  Some progress has been made in delivering that vision and, however difficult the current circumstances, now is not the time to draw back.  However, given the scale of financial and workforce pressure in the system, delivery is not straightforward.

The Refresh is clear about the givens. Brexit is Brexit and the money is the money.  Whatever happens will happen within the funding committed in the Comprehensive Spending Review and the next two years are the toughest ones in the settlement.  There is little room for investment in the double running of services and activities which would smooth the process of transforming services, very little room to deal with anything new or unexpected such as a genuine flu epidemic, very little scope to address the financial pressure on NHS staff, especially at the time when Brexit will exacerbate staffing pressures, and very little room to get anything wrong.  It’s not impossible but the margins are immensely tight, as anyone of us involved in driving a STP delivery plan is more than aware.

However that is the hand which Simon Stevens has been dealt and which he, in turn, has to get the NHS to operate within.  Unless political pressure plays out with a different dynamic than it has over the last 6 months, and something did shift on social care, then the chances of new money remain very low.  There are, though, some important commitments which might make a difference.

First there is a clear and consistent set of priorities: finance, A&E, primary care, mental health and cancer.  In the circumstances these make sense and I am pleased to see the commitment to mental health followed through again although there is still much to do to make the funding flows required to deliver the Mental Health Five Year Forward View objectives clear and transparent.

Second there is a recognition that something else has to give in the form of waiting time targets for some routine surgery and treatment. This will not be without cost for individuals who will face longer periods of distress and anxiety as they wait for treatment, something which in mental health, without historic waiting time guarantees, we are all too familiar with.  There must also be a concern that this is the beginning of a process by which the NHS consolidates as a universal service around urgent care.  Nonetheless in the circumstances it may be the least bad thing to do.

Third there is the commitment for budget flexibility in relation to the rollout of new drug treatments. This will again not be without cost but I have long felt that it was unjust that new drug treatments and the commercial interests of the pharmaceutical industry trumped basic access to care in areas such as psychological therapies.  Unless we see substantial new growth in future funding for the NHS we will need, in any case, to see a radical overhaul of thresholds for approving new drugs and treatments with a much greater emphasis on those with a genuinely transformational impact and less space for “Me toos”.

Finally it was interesting to read the intention to put the nail in the coffin of QoF which the Refresh describes tactfully  “as an approach which has run its course”. As I remember from the time, its intentions were well meant but as a mechanism for driving genuinely health improvement it has become discredited. Hopefully there will be better ways of spending £700 million.

It takes until Chapter 8 until we reach the issue of Workforce and yet nothing could be more significant, both to managing short term pressures and to longer term hopes of transformation. Workforce pressures and issues have been central to some of the biggest financial and quality challenges over the last couple of years, epitomised by agency staffing.  They perhaps have a bigger profile in the Refresh than they did in the original Five Year Forward View but the NHS has a consistent record of not giving workforce the attention it is due.  That cannot be the case over the next couple of years.

There are three challenges. Keeping the numbers on track at a time when retention may be difficult with ongoing pay restraint and the impact of Brexit.  Reskilling the existing workforce to work in the very different ways required by new models of care, perhaps the part of service transformation which mental health took longest to get right in respect of the closure of the long stay hospitals.  Finally the challenge of maintaining staff morale and wellbeing when anxiety is high, pressures are increasing and pay restraint likely to continue.

As we enter the new financial year it is a good time to take stock on where we’ve got to. The Refresh deliberately accentuates the positives and, despite the pressures which most of us can feel trying to manage the system, it is right to celebrate some of the significant achievements of the last year including the introduction of the first waiting time targets for mental health.  In the last year the NHS and its staff have shown great strength, commitment and resilience to achieve what they have in such difficult times.  While the direction of travel still remains the right one it will take a lot more hard work and resilience to get to the final destination.