We Have a Power Problem!

NHS – we have a problem! This blog forms a hiatus in the middle of a 4 blog mini-series about what I call the four rings of leadership (in the context of healthcare). I have been musing on some statements made at the IHI conference in London, Quality 2017, and before I go any further, I want to take a pause to reflect on the notion of power. Helen Bevan says that the number one issue facing our health care system is the issue of power. I would suggest that unless we seriously reflect on power and how it manifests itself in our systems and in us as individuals, then we will never be able to co-create health and well-being in our society.

 

In my last blog, I mentioned an excellent talk that I heard Derek Feeley of IHI and Jason Leitch, the CMO of Scotland, give together about our need to “cede” power, if we are to build safe, high quality, economically sustainable health systems. They contend that we need to move from keeping power, to sharing power and then ceding power. To cede power, means to transfer/surrender/concede/allow or yield power to others. I do believe this is correct. I believe that true leadership is absolutely about being able to ’empty out’ positions or seats of power, so that all are empowered to effect positive change and build a society of positive peace. However, my contention is this: ceding power is not helpful unless we first deal with the very nature of power. Once we have dealt with its very substance can we truly cede it through our organisations and systems to bring increased well-being for all.

 

I have talked many times over the dinner table with my great friends Roger and Sue Mitchell about the nature of sovereignty and power. Sovereignty is a dominant theme within our political discourse at the moment, at a national and international level. It is worth reflecting that sovereignty (the right to self-govern) is utterly intertwined with our understanding of power, and we need to pull the two apart if we are ever to cede the kind of power that can transform the future. If we do not recognise (have a full awareness/deeply know) this, we will continue to inadvertently create hierarchical dominance and systems that become the antithesis of what they are created to be.

 

 

We see the issue of sovereign power at work every day in the NHS. We see it in terms of power edicts from on high, without understanding the local context or issues worked through in a relational way. We see it in the way these edicts are then outworked through leadership and management styles, which are very top-down and hierarchical in nature, eating up people like bread in the process – what Foucault calls “Biopower”. We see it in the way wards are managed and in the way GP surgeries are run. Sovereign power says “I’m in charge around here” and “we’re going to do things my way”. We see it in individuals who choose to practice autonomously without thinking about the wider implications on the system, prescribing however they would like to, without thinking about the cost implications. We see it in the attitude of some patients, when it becomes about “my rights” with an unbearable or unaffordable pressure put onto the system. If we multiply sovereign power, we simply end up with lots of  kings and queens who defend their own castle, creating more barriers, walls and division in the process. Sovereign power is defunct and dangerous and it is this which is currently destroying our ecosystems and wider society. The “I did it my way” approach is rooted in self preservation and ambition and does nothing to help us build health and well-being in society. Sovereign power stands in the way the very social movements we need to see, because Sovereign power is based on fear.

 

Sovereign power has its roots in certain streams of theology and philosophy which have in turn laid the foundation for a way of doing politics and economics based on the supremacy of the state and within that the individual. However, the damaging effects of this are seen on our environment and on community, with utterly staggering levels of inequality, injustice and damage to the world in which we live.

 

If we are to truly cede a power that is effectual in changing the world, then it is not enough to simply reconfigure (rearrange) it, or reconstitute it ( i.e. give it a new structure/share it). First of all, we must revoke it! In other words, we must look ‘Sovereign power’ straight in the eyes and reject it, cancelling it’s toxic effects on our own selves and on that of others. We must change our minds about it and embrace instead a wholly different kind of power. Sovereign power has not changed the world for the better so far, and I hold no hope of it doing so in the future. No, we don’t need Sovereign power and we certainly don’t want to cede it. Instead, we need kenotic power. Kenotic power is based in self-giving, others empowering love (Thomas Jay Oord). It empowers others, not to live like mini-dictators, but to also dance to a very different beat.

 

I used to play the card game bridge, with my Grandpa (he was an amazing man, who invented Fairy Liquid!). In bridge, to revoke something is to fail to follow suit, despite being able to do so. Kenotic power refuses to play the game of Sovereign power. It embraces an entirely different approach. And as many through the ages have found, this kind of power is truly costly, and can even cost you your career or life; but it is the only kind of power that truly changes the world for good. Jesus, Rosa Parks, Emmeline Pankhurst, Gandhi, MLK, Malala Yousafzai, Nelson Mandela, Florence Nightingale and Mother Theresa are just some, who have embraced this ‘self-giving, others empowering love-based power.’ This is the kind of power we need now. We need it in healthcare and in every other part of our society.

 

Kenotic power is vulnerable but it is not about being a door mat. It is like a beautiful martial art, in which we can say “I won’t fight you and you can’t knock me down, unless I let you” In other words, we lay down our rights and power freely, they are not taken from us by force. So, even when energetic attacks are launched against us, this kind of power allows us to move out of the way, allow the attack to pass through and then to come along side the person and help them see another point of view. Switching to this kind of power is far more creative, less combative and far more fruitful in creating a way ahead full of possibilities without the need for making enemies in the process. We must challenge the deep structural belief that our political and economic systems must be built on and can only be held together by Sovereign power. What if we developed systems based on love, trust, joy and kindness, aiming for the peace and wellbeing of all (including the environment?) – what might such a health system be like? It will take a social movement for us to get this shift, and as I wrote in my previous blog: You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well.

 

 

I agree wholeheartedly that the most important role of leaders is to cede their power, so that all can truly flourish, where there is a far greater sense of cooperative and collaborative agency within our (health) systems. But if we do not examine the nature of this power, we will only perpetuate our problems.

 
Martin Luther-King said these famous words – they are seriously worthy of our reflection:

 

Power without love is reckless and abusive and love without power is sentimental and anaemic. Power at its best is love implementing justice, and justice at its best is power correcting everything that stands against love.”

 

 

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Creating a Culture of Joy in the NHS

A Culture of Joy is the biggest determinant of safe and high quality healthcare! That is such a phenomenal statement that it is worth reading over and over again, making it into a poster, sticking it on your wall and meditating on it morning and night. It feels to be simultaneously absolutely true and somehow beyond belief. I’ve previously blogged here about the need for a culture of kindness in the NHS, and I hold to that – kindness certainly doesn’t exclude joy (!), but a Culture of Joy….. I don’t know, in a day in which 50% of our staff admit to feeling burnt out, can we honestly say we have developed this throughout our health system in the UK? So, what does it take to build this? How do we have a joyful workplace? If it is really the single largest factor affecting patient safety, which research from The Mayo Clinic, The IHI and The Quality Forum tell us it is, then we better sit up, pay attention and do something about it!

 

There are 3 key ingredients to creating a culture of Joy.  The first (and this is in no sense a hierarchical order!) is leadership, the second is how
teams actually function together and the third is personal responsibility. You will see the words incorporated from the ‘culture circle’ in bold!

 

Good Leadership: Here’s a fascinating fact, I learnt from Stephen Swensen, of The Mayo Clinic – The bigger the signature of a CEO, the worse the outcomes for patients, staff and the finances of the organisation!! CEOs are responsible for setting the structures in place that allow healthy cultures to develop. Leaders create a culture of joy by having humility and developing 5 key behaviours:

 

  1. Appreciation – good leaders build joy in their teams by saying ‘Thank You’ – it is one of the things the team at my surgery consistently tells us, as partners. Of course we are grateful, but we don’t say it enough. Every member of a team knowing that they have value is so vital. I remember, as a house officer on a medical ward watching a lady called Jean, cleaning the ward and saying hello to all the patients. I went up to her and said, “Jean, I just want to thank you for everything you do on this ward, every day. The way you keep this place clean helps fight off infections and keeps people well; and the smile and kindness you bring is really comforting to people who are scared or hurting.” To my great surprise, she burst out crying. I asked her what was wrong and she told me that she had worked on this ward for 25 years and no-one had ever said ‘Thank You’ to her. My favourite hashtag on twitter is trybeinggrateful – it costs so little.
  2. Transparency – good leaders communicate openly with their teams. They don’t do ‘special huddles’ in which they invite a few ‘high level’ people to know their secrets. No. They communicate with honesty and openness and this builds trust. And with trust they are able to negotiate difficult situations and requests of their teams, because there is a belief that everyone is in it together.
  3. Ideas – They look to their teams for ideas. One of the things I loved learning about recently is that the CEO of Toyota in Derby, deliberately does not park his car in the special ‘CEO parking space’ right next to the building. Instead, he parks it at the far end of the factory, so that the walk to his office takes him through every department, (a good 30 minutes of his time), so he he can say “hi” to his staff, connect with them and ensure that he is hearing about their ideas for innovation and improvement. Toyota takes 2.5 million suggestions from its staff every year. This simply doesn’t happen enough in the NHS, and I wonder how many CEOs take time at the start of the day, to walk the corridors, listen to patient stories, understand the pressures in the ED, hear the heartbeat of the wards and get a sense of the ideas brewing in some of the most compassionate, caring and intelligent staff of any organisation in the UK. If we are to transform the NHS into a system that is truly safe, sustainable and excellent, we must listen more to the ideas of our teams and in doing so, we will cut waste, undo the reems of red tape and instead find we are working far more effectively and efficiently. To embed this into the culture, there must be psychological safety – that means that no question is too stupid, no idea is too dumb and it is safe to bring to attention concerns a person may have, without a fear of retribution. One great question for leaders to ask is, “what are the pebbles in your shoes?’ – in other words, what matters to you? Or what are the barriers for you here? What’s getting in the way? Great CEOs do not have great answers, they are willing to work with complexity and have great questions!
  4. Career Mentorship – every person needs to be able to keep learning and develop in their role. We all need mentors or coaches at different stages in our careers, and ensuring these structures are in place to support staff as the complexity and pressure we deal with increase, is vital in building joy. People who are developing in their role are naturally safer in their role.
  5. Inclusiveness – To a good leader, it doesn’t matter who you are, what you look like, what you believe, what your sexual orientation or status might be. You need to know that you are welcome and you are loved just as you are. Inclusive teams that do not scapegoat, do not sideline and do not bully are joyful teams. Joyful teams celebrate difference and thrive off it.

 

Joyful Teams:  It’s really important to understand that joy does not mean false happiness. It does not mean that we walk around with fake smiles on our faces all the time and pretend that everything is ok. Joy is much deeper than that. We deal with very sad and difficult things in our workplaces every single day. We break bad news, we hold people as they take their final breaths, we watch people make terrible life choices, we see and carry the hurt of those who suffer loss and each of us has our own burdens we carry from the lives we live outside of work. Joyful teams do not pretend like that stuff isn’t happening every day – quite the opposite. Joyful teams develop three key qualities:

  1. Camaraderie. The high school musical song – ‘We’re all in this together’ is a great theme tune for NHS teams. People need to know that they belong, that they are loved and that people care about them. On good days, we celebrate together, on bad days, we pull together. Joyful teams develop encouragement, support and kindness in how they treat each other.
  2. Purpose. Joyful teams have a real sense of shared vision and purpose. They know what they are there to do and each person knows that they are valued in that team. The posh term for this is a sense of corporate agency. This is our job to do, we are responsible for what happens here and we want to do our work with excellence. 
  3. Trust. It is really important that individuals feel trusted to do their job without feeling like they are always being watched or criticised or that they have to give an account for every action. When people feel trusted, they actually work more effectively and produce better outcomes.

 

Personal Responsibility: in order to create a culture of joy, it is not just the responsibility of the CEO or team leader, nor the atmosphere created by the team as a whole – we each have a responsibility to steward and hold to this culture. And that means taking care of our own needs. We need to be active, eat well, take notice, be mindful, sleep well, forgive those who hurt us and have good friendships. Making sure that we ‘host ourselves’ well, ensures that we play our part in building the culture of joy that is so vital to the providing care that is of the highest quality and safety. There is a personal accountability to ourselves and to those we work with to ensure this is so. There is also personal agency that rises to the challenge that each one of us can set a new trend and make a significant difference to the culture in which we work.

 

In the midst of all we are currently facing in the NHS, for the sake of our patients and their families, it is vital that we build cultures of joy now and cultivate them for the future.

 

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Just to be Clear – This is a Social Justice Issue

Following on from my blog earlier this week, I want to be really clear in what I am saying!

  1. The funding formula used in health and social care is weighted towards the wealthy and the well…therefore the north is worse off compared to the south…
  2. We are already at a major deficit in terms of health outcomes, in the north
  3. The cuts affecting northern county councils were deeper and harder – both in terms of public health and social services, with a profound knock on effect to the NHS – therefore the further ‘efficiency savings’ being requested of us have an even more detrimental effect
  4. The actual investment from the government as shown by the King’s fund is not 8-10billion as promised, but only 4.5billion
  5. If you take into account economic growth, inflation and population need, the ‘investment’ is actually a disinvestment…..
  6. On top of this is the fact, shown through HEE (Health Education England) that the NW in particular has a massively reduced investment in recruitment compared to other areas, which flies in the face of what the Nuffield Trust and King’s Fund have shown is needed in areas of higher deprivation and worse health outcomes
  7. Even if we save the £560m we’re being asked to as an STP, our deficit at 2021 is £804m

My argument is this: if the correct investment was made, the formula wasn’t weighted against us and we therefore received the correct allocation of resource according to the task ahead of us, we would actually probably be in surplus and could really make a difference – we are already doing loads of great stuff, but asking us to make bricks with no straw is beyond the pale.…..as it is, what we’re being asked to do may affect the health and wellbeing of our population negatively because we are already at such a deficit, before we start….

 

This is not a political issue – this IS a Social Justice issue.

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Why Are We So Inactive in the North West?

So, I was interviewed on BBC News 24 on Monday evening (sorry for the poor visual quality), to talk about why it is that we are so inactive in the North West (worst in the country, apparently at 47% being inactive).

We have also pretty much the worst health outcomes, with high rates of obesity, heart disease and Type II Diabetes. Maybe we can muster our Northern Spirit and do something about this together? We may have the odds stacked against us with the weather (!), our work-life balance, long working hours and various other factors, but being active is so good for us and helps our health in so many ways – let’s cut the excuses eh? Maybe it’s time for a cultural shift?! Time for healthier workplaces.

 

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Building a Culture of Kindness in the NHS

My morning surgery began today with a patient of mine, who works as  Health Care Assistant (or Band 3) in our local acute hospital trust. As we find across the board in the NHS right now, there are pressures in her department with under-staffing and a very high and demanding work load. She started her day in tears, telling me about the sleepless nights, but even more so about the lack of support she is feeling in her work environment. She feels unable to understand why huge fees are paid to find locum consultants, when posts are not covered, but money cannot be found for the absence of staff at her level, when the numbers are down, leading to an increased pressure and low morale.

 

Now, this is not a criticism of the acute trust we partner with every day, because I actually know all too well the situation here, how complex it can be and just how dedicated to caring for staff the leadership of the trust are. However, when we read in the press today about sickness absence for stress among paramedics, and if I were to detail more stories about the number of cases I am currently dealing with as a GP about stress in the workplace for ALL grades of staff in the NHS and social care setting, then we have to face up to the fact that we have a problem. Stress in the workplace and low morale in our teams is not a problem we can afford to ignore. It not only causes high sickness rates, which then increases the pressure on teams, with knock on financial implications to the system; it also causes significant compassion fatigue (i.e. staff are literally less able to care about or for their patients), because they are emotionally overwhelmed, under-resourced and therefore become more numb, disengaged and unkind and this is detrimental to patient care.

 

The problem is actually really complex, but it is, in my opinion, primarily cultural, and particularly affects the lower pay-grades of staff, because they feel and are in fact less able, to influence change. If we do not develop a culture of kindness towards our own teams and have a sea-change within our working environments in terms of how we care for each other, we will only see the problems go from bad to worse. So, how do we create a culture of kindness, a culture of honour, a culture of wellbeing?

 

I would like to suggest six things (all beginning with H – the 6Hs), which are fairly simple, but make a massive difference to how teams function and therefore the morale within those teams:

 

  1. Humanity – First, we must recognise that hierarchy has the inbuilt tendency to de-humanise us. As we get higher in the pyramidal systems in which we work, we can easily lose our humility and compassion towards others as we have to cope with the greater demands from “above us” and if we’re not careful we can turn into slave drivers. Top down, controlling leadership is detrimental to good morale and stifles teams from working effectively.  There is a famous, ancient parable (told in the New Testament) about an unmerciful manager, who owed a huge amount of money to his master/CEO. The CEO called him to account and threatened to fire him. However, he begged for mercy and the master cancelled his debt and gave him a fresh chance. However, this same manager then went and found all the people who owed something to him, and instead of paying forward the mercy he had received, treated his own debtors shamefully, despite their begging and pleading for mercy. When the CEO found out about this, the manager was duly fired. I wonder how often we tolerate ‘bullying’ by managers, because they ‘run a tight ship’, without calculating the cost of this style of management on our teams and the patients we serve? Changing culture is hard. Even if the CEO sets a good culture, any one of us can bring a negative influence in the area we work. We have to make a conscious choice to keep our kindness switched on. As we climb the ladder of responsibility, we must continue to act with humanity. We must also remember that it works the other way round – we can start dehumanising those in leadership positions ‘above us’, or those who work in different teams. We make terribly unfair assumptions about people all the time. A little bit of understanding, kindness and compassion goes a HUGE way in treating each other with kindness instead of suspicion.
  2. Humility – For those in leadership, there can be a tendency to forget that when we were in in ‘lower’ positions, we often felt the same low morale and pressure from those ‘above us’. Leadership requires that we keep our love and compassion switched on towards those who we now lead. This means we must really learn to listen, and that means having the humility to recognise where we have been getting it wrong. If we are not prepared to change, then we are not really listening. It takes courage to create a culture in which we can receiving a challenge from those in our team and be able to make a change and not just use our position to squash the person who dared to speak out. It takes even more guts to admit where we have been wrong, say sorry and move forward differently.
  3. Help – one of the very worst things that can happen in any team dynamic is when we hear the words ‘it’s not my job’. I hear it so often and it makes me sad! We must never think we are above any task – whether that is cleaning up a mess, wiping a patient’s bum or picking up some litter. We must simply help each other out. But we also need the humility to admit when we are struggling and actually ask for help. We encounter terrible and unspeakable trauma at times, or may simply be going through tough personal circumstances. Sometimes, we need the humility to recognise where we are not coping, where we are struggling, when we’re not functioning and ask for help. And when we ask for help we need to have the confidence that we will encounter the humanity of those around us to help us at our time of need.
  4. Honour – Sometimes a situation may not be able to change, but in these situations the very worst thing leaders can do is close ranks, shut communication down and raise the levels of demand. No, vulnerability, openness and honesty, sharing the reality of the situation and communicating clearly why things cannot change currently at least allows the team to pull together and face the situation as one. However, there must be a very clear challenge here – Yanis Varoufakis puts it so well in his book “And The Weak Suffer What they Must” – we have to remember just how crippling powerlessness can be. Like my patient this morning, she has no access to the ‘powers’ or to the ‘purse strings’. She cannot up and leave, she simply can’t afford to, and so she works under huge pressure for very little pay, powerless to enact change, other than to put in place her own boundaries. A cultural shift towards a culture of kindness is to ensure that those with the least ‘honour’ are treated the most honourably. Leadership is about being able to take the hit, not self-protectionism at the cost of ones team. It is absolutely amazing just how far the words ‘Thank You’ can go, to keeping this sense of honour alive.
  5. Health – (by health, I mean wellbeing in its widest sense) – we have to actually care for the people around us. We have developed a culture in the NHS and social care where we will do all we can to care for our patients/clients, but will break the backs of ourselves or our teams in the process, which is actually entirely self-defeating! It is impossible to care for others well, when you are feeling exhausted and broken! I have said it on this blog before and I will say it many times again: we have to develop a sense of the health and wellbeing of the people in our teams. We need time in the craziness and business of each day to stop the mad rushing, be still and take notice/be mindful/be heartful. We all need time to get up off our chairs and stretch and be more active – #runamile every day (it only takes 15 minutes). We need time to connect with each other (do we really take time to know the people we spend an inordinate amount of time with and alongside and check they are actually doing OK?), to eat well, stay hydrated and keep learning, so we don’t feel overwhelmed. Building these as an absolute priority into our daily work routines is vital, especially as pressures increase. The tendency is that when the going gets tough, our health gets significantly worse. We must learn to protect this in the midst of our business, or we will suffer the consequences in multiple ways.
  6. Hope – there is an ancient proverb that says: “hope deferred makes the heart sick, but hope coming is a tree of life.”  Hopelessness takes root when we feel that nothing can ever change and we feel powerless to influence anything. Hope is born when we develop ways of working in which teams can work together on solutions to the problems they are encountering, rather than being dictated to from on high in a unrelational way. Hope is about being able to sense that the future is alive with possibility. It is a life line when things are tough, when the tunnel is long and dark – just a little glimpse of light – and then faith builds that together we can get there.

 

Not difficult. Actually pretty straight forward. We don’t need unkindness or low morale in our work places. We don’t want to be suffering with compassion fatigue because we are physically and emotionally drained and running on empty. We really can create the kind of culture we want to see and experience in the NHS and social care – a culture of kindness – sounds nice doesn’t it?! All it takes is for us to remember humanity, humility, help, honour, health and hope.

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The Morecambe Bay Mile A Day!

Every day in Morecambe Bay 2000 children aged 4-11 run a mile a day (how fantastic is that?!). Inspired initially by the story from Stirling, the word  is spreading and we now have another 3000 children starting across Lancashire. Our early data shows that there has been a dramatic improvement in the children’s health, from a physical, mental and educational perspective. 15 minutes a day for a healthier, happier child who is able to sleep better and concentrate more in class – it’s an absolute no brainer. And what is more – if it’s good for the kids, then it’s good for us all. We will all be more physically healthy, more mentally well and be more productive in our work if we just take a break (especially in that post-lunch lull) and do some exercise! Who amongst can’t spare 15 minutes a day? And for those who can’t run, there are other alternatives. Some of our kids here are cycling or walking or even using hand bikes according to their physical ability, but everyone is taking part. Even on rainy days, they just get out there, or if it’s especially vile, they do some aerobics or zumba in the classroom.

 

The challenge is this: if kids 4-11 can move a mile a day…..can’t we all? What if it became part of our culture, here in Morecambe Bay and further afield that everyone is given space in their educational or working day to run or move one mile each day? One mile – 15 minutes – easy!

 

Today, Simon Stevens, head of the NHS, will highlight that we are now half way through the 5 year period he launched to help transform the NHS. Across the UK, there are now 44 STPs (these stand for Sustainability and Transformation Plans). In order for the NHS to be sustainable in the future, there needs to be some transformation – it’s simple really. There are plenty of conversations happening about how the system itself can work more efficiently and many new ways of working are being trialled and forged. However, we all also need to transform the way we are living, as our current lifestyles are making the NHS have to deal with pressures it simply can’t cope with anymore. Part of our work as an STP in Lancashire is to work with our population to encourage us all to be more healthy and well in our daily lives. It isn’t rocket science. Simple, small steps go a long way to making significant changes to our health. The 4-11 year olds have laid down the gauntlet – one mile a day – a simple first step that packs a real punch. The NHS and City Council will be following in their wake. One of our headteachers lost 3 stone in 6 months just by following their lead…….let’s get moving, let’s be healthier and let’s have an NHS that is therefore more sustainable for the future. The Morecambe Bay Mile a Day could easily become the UK Mile a Day. (Also see The Daily Mile Foundation).

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The Art of Hosting Good Conversations – Morecambe

Here is a video about a brilliant couple of days a bunch of us had in Morecambe, talking about how we discover what it is to be healthy and be part of a social movement to improve the health and wellbeing of everyone:

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Our Nation’s Biggest Public Health Problem

The subject of this blog is sensitive and difficult. It may stir up some difficult issues or memories for you, as you read. If this happens, then please take time to seek the help you need. I believe this blog and ones to follow might be some of the most important I have written to date.

 

UnknownI am currently reading a phenomenal book, sent to me in the post, by a dear friend of mine, who is a trained counsellor and knowing the work I do, felt that I should read it also. The book is called “The Body Keeps the Score” by the eminent Psychiatrist, Bessel Van Der Kolk. In my humble opinion, it should be compulsory reading for every person training in any of the clinical specialities, including public health and for those working in education. The book focusses on the detailed research and work done by Van Der Kolk and others at Harvard over the last 30 years in the whole area of Complex Post Traumatic Stress Disorder (CPTSD), or “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS). It is not a part of our vocabulary, unfortunately, because even now, after a huge evidence base and many studies, there still remains no such psychiatric diagnosis. However, it is a hidden epidemic affecting huge numbers of our population and is the root of many of our major public health issues. So what causes this problem and just how wide spread is it? The evidence shows so strongly that the cause of CPTSD or DESNOS is Adverse Childhood Experiences, which we more starkly call Child Abuse.

 

Child abuse falls into four main categories: Physical abuse, Sexual Abuse, Verbal Abuse and Emotional abuse – usually in the form of neglect. 10% of children suffer regular verbal abuse. 25% suffer regular physical abuse. 28% of women and 16% of men have suffered sexual abuse. 16% regularly watch domestic violence. 87% of all those who suffer one type of abuse, are also abused in other ways. Each of these forms of abuseUnknown lead to major health problems later in life and studies are showing that it is not just mental health issues (many of which lead to inappropriate diagnoses like Borderline Personality Disorder or Bipolar Disorder and ineffective treatments) but also major physical health problems. Those who have been abused are twice as likely than others to develop cancer and four times as likely to have emphysema. The more difficult a person’s experiences, the higher the chance of developing heart, liver or lung disease at an early earlier age with much higher chances of taking more health risks with smoking, becoming overweight or having multiple sexual partners. There is good evidence to suggest a link with autoimmune diseases, such a lupus, and other complex conditions like chronic pain, chronic fatigue and fibromyalgia. The body cannot be separated from the mind and literally keeps the score of the internalised turmoil. So, even if the abuse happens before memories are formed, or our minds manage to forget or block out what has happened, the body simply cannot forget and sometime and in someway, the damage will show itself. Studies show that the overall cost of this appalling reality far exceed those of cancer or heart disease. In fact, eradicating child abuse would cut depression rates by over 50%, alcoholism by 66% and suicide, IV drug use and domestic violence by 75%. Antidepressants and antipsychotics are now some of our largest prescribing costs. We know this, but are doing very little about it. Perhaps it feels too big. Perhaps we don’t want to face the demons involved. Instead, we are numbing the problem, trying desperately to get people to be just functional enough to keep on serving the needs of our economic system, but we are not facing up to or dealing with this horrific problem, nor its true cost.

 

What can be done in the face of such evil? How can we develop aimages culture of compassion and restorative justice in which we can find a new way through for humanity? It isn’t getting any better. It is just as widespread and far reaching in its consequences as it was a generation ago. Is it possible for us to face up to the startling reality we face? Van der Kolk offers much hope, but it is not within the gift of the health service and social services to tackle this alone. If we are to take this issue seriously, we must embrace what Bessel refers to (at the end of chapter 2) as four fundamental truths:

 

  1. Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing.
  2. Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know and to find a common sense of meaning.
  3. We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through simple activities such as breathing, moving and touching – (learning to be present in our own bodies is a vital way of separating out the memories of the past which can overwhelm us at times).
  4. We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

images-1People can be healed of trauma. We need this at both an individual and corporate level. We have become so focussed on saving money, on quick fixes to ensure the NHS and Social Care System can survive, but we are ignoring the root cause of many of our ill health issues. If we are willing to face up to the truth of child abuse in our society and its long lasting and far reaching impact on overall health and wellbeing, then we might just be able to find a way through to healing and restoration of what has become an extremely broken society. In the blogs that follow, I will look at some of the ways we might find a way through this crisis of epidemic proportions. One thing we must face straight away is that we are spending our resources in the wrong places and are focussing our attention in the wrong areas. We must protect our children and help people learn how to be good parents. We must strengthen our school teachers and sense of community. We must invest in the first five years of life far more than we are doing so currently, especially those key first 12 months of bonding and attachment. Together, if we want to, with love, care, bravery and determination, we can change the future. There is hope. There is healing. Our systems are not yet designed to cope with this, but we must speak the unspeakable, break the silence and face up to the truth. The truth will set us free and enable us to develop the kind of wellbeing that every human being should be able to live within.

 

 

 

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We Need to Be Ambidextrous in Solving our Health and Social Care Conundrum

UnknownAll this week on the BBC, there has been a focus on the NHS and the crisis we are in – don’t panic Mr Mainwaring…..There is a heady mix of opinions being thrown around – Question Time became quite a furore of ideas and thoughts last night – not enough beds, not enough staff, not enough money, too much money, too many patients, too many wasted appointments, too many malingerers, too many ill people, too many old people, too many managers, too many drugs, too many drunkards, disappointed clinicians, disappointed patients, disappointed MPs, a disappointed health secretary – what are we to think and what are we to do?

 

imgresWe love the NHS because it speaks something to us about our togetherness and our commitment to health justice for all. This circular argument about money is the wrong conversation and it is beginning to have a very nasty undertone about who we might be able to blame and scapegoat in order to solve the mess we are in. Let’s be very clear. The NHS is NOT in crisis because of refugees, asylum seekers, immigrants or health tourists. I’m going to stick my neck out here – it isn’t even the fault of the current and previous health secretaries, though it would be easy to play the blame game that way too. The NHS is in crisis, because the entire Western World is in crisis! Our economic systems are broken and our political systems are pretty defunct. We have built our nation state on the foundations of empire. We have built our economy on conquest and slavery and have used debt, violence and law to keep control….but everything is shaking.

 

There are some difficult truths for us to face up to. Are we brave enough to accept that things cannot remain as they are? Are we imagesLYB84K5V.jpgbrave enough to rewire our brains, realign our values and reimagine a different way of being together? If we accept that things simply cannot remain as they are, might we instead find one another in fresh ways and discover new ways of being in which we’re not always chasing the money, with all its strings attached, but choosing something altogether more life giving?

 

images3W7WQ07WI would suggest we need two things (an ambidextrous approach) – both of which are already happening, we just need to recognise them, fan the flames and watch the new emerge, whilst Rome burns around us.

 

The first thing emerging is a grass roots people movement around health, wellbeing and a kinder society. Think of this as the left hand. We must take a left handed approach to really listen to and engage with our communities. Many people are waking up to the fact that we are eating in ways that are unnatural and completely unhealthy for the human being. Global corporations like GSK have shoved Lucozade and Ribena down our throats and then very kindly provided the medication for the diabetes we have developed. Enough! Thankfully, peopleimagesOP6FM73O.jpg are beginning to think about how we are living and making a change. It’s a tough reality, but there is personal and corporate responsibility that we need to take. We cannot keep shoving poison into our bodies or treating them badly and expect that we will be well, or that we will be able to afford the drugs to fix us. Social movements are beginning to emerge and we need to be a part of them. Together, we can! Together we can cause corporations to change their behaviour and act in accordance with what is right, true, just, kind and loving. We can also choose to take responsibility for what we buy and how much exercise we do. Here in Morecambe Bay we are launching the Morecambe Bay Mile, encouraging everyone to move a mile a day without transport! We’re also working with our communities around diet. We’re also connecting with amazing people doing amazing things and seeing just how much kindness and goodness there is in the communities around us. Our happiness is directly linked to the quality and depth of our friendships. People being together and facing up to the issues together is absolutely key to our long term health.

 

imagesBCV6CE7Y.jpgSecondly, we must stop serving the system, re-humanise it, call it in line and cause it to serve the needs of the people and the planet (the right handed approach). Those in the health and social care system must refuse to be bullied by the powers into ways of behaving, stop thinking they have the answers and therefore coming up with another new scheme to do to people and be willing to listen to and work with the emerging social movements. This will allow us to see a society that is much more well and therefore in need of less care. But where care is needed, we have to accept that we have allowed ourselves to be competitive rather than collaborative, hierarchical instead of co-operative and our own attitudes and behaviours are stopping us from giving the compassionate care we long to deliver. We cannot make excuses. We must let go of self-protectionism. We must be willing to change the way we think and behave, breaking down walls, letting go of suspicion and cutting through red tape so that we provide the care which we can. This is happening, here in Morecambe Bay – but it’s not a quick thing. We are rediscovering the power of relationship and daring to make some bold steps into delivering care very differently – but for those of you outside the system, please understand, it takes time and feels pretty scary!

 

I believe it is possible for the NHS and Social Care System to be radically transformed at this time. It might enable us to model something for the rest of the world. That in our time of crisis, we did not sell out to the lie that the only way ahead was privatisation and insurance – (in our hearts, we know this isn’t fair and it doesn’t work for everyone). No – instead we chose to work with a grass roots people movement, calling for us all to beuntitled.png more healthy and well and we changed our ways of working to be more collaborative and kind. It is this ambidextrous approach to health and wellbeing, in which a heady mix of an invigorated people movement and a reorientated system working together for the good of everyone everywhere, might breathe hope into other parts of the world that out of the old can come something new. Maybe it is just possible that healthcare can be provided for everyone everywhere when people are brave enough to let go of old ways, embrace the brokenness of our reality and find a new way through together.

 

untitled.pngI’m telling you – it is nearly Spring time and the bulbs are beginning to break through. Can you smell the scent of something new emerging? Those rhizomal roots of the snowdrops – that interconnected underground network that shoots up its flowers, is telling us the winter of discontent is over. It’s time to turn off the radio, dial down the meta narrative of fear and instead, put on love, hope and faith, find each other, change our ways of working and step into the future we know our hearts yearn for.

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Doing the Impossible – Turning the Tide!

It’s time to do the impossible. It’s time to turn the tide.

imgres.jpgIn my last blog, I talked about the exponential potential of what could be possible if clinicians worked together in a more collaborative way. However, far more can be achieved if we work together in and with our communities to create a social movement together around being more healthy and well. I’ve talked previously about the “battle royale” that occurred between Béchamp and Pasteur over whether we should promote health or fight disease. The answer is, of course, that we need to do both, but the clinical community is not equipped with the resource or power to do it alone.

What we cannot accept, though, is our current apathy or malaise that some of the health imgres.jpgcrises we now face are too much for us to do anything about. We are in the midst of a battle, which we are currently losing and it is time to gird our loins for a turning of the tide. Here in Morecambe Bay, we have started a conversation, not just among the Clinical Community but with the wider population about how we might become the healthiest place in the UK. Yes, we mean this in a very holistic way, but there are also some specific foci we have so we can together reverse some of the appalling health statistics we are facing.

For too long, we have simply laid down and allowed exercise to be taken out of schools, whilst our kids consume a bath full of sugar every year. All the time our own work and eating habits have become significantly unhealthy. We have relied on expensive drugs to fix our problems, rather than tackling the root causes of our excesses. It has lead to 1 in every 5 pounds in the NHS being spent as a direct result of our lifestyles and 1 in 11 pounds being spent on diabetes. We say we value the NHS above anything else as a nation (maybe an issue in it’s own right…..) but we do not behave in ways that show this value to be true. We have not been brave enough to challenge the status quo and together make a wholesale change both about how we promote health and look to aggressively reverse it when things begin to go wrong.

images.jpgI suggest that within a generation, if we wanted to, we could render Type 2 Diabetes a rare diagnosis. We can do this through encouraging far more healthy lifestyles in our children and young people now, like running a mile a day and learning to eat food that doesn’t actually harm them! I believe we could significantly reduce the need for so many people to be taking medication for hypertension and diabetes now, prevent many strokes and heart attacks, by being violent towards these conditions with major changes in lifestyle, though diet and exercise, rather than the prescription of drugs, using coaching, peer support and local champions to give psychological motivation and encouragement. We are beginning to have some excellent discussions and develop some exciting plans around this.

Our NHS health checks should serve as a major motivational opportunity for someone toimgres.jpg pull themselves back from the brink of a lifetime of medication and we should use all medication reviews as a chance to help people adopt lifestyles that might reverse the need for such drugs. In the process, we would also significantly reverse our number of cancer diagnoses – many of which are linked to our lifestyle choices. We simply can’t afford for our current and failing approach to continue. We need to be braver together! And this means the NHS must be willing to partner in new ways, not only with local people, but also with businesses like the major supermarkets to help reverse our current direction towards the abyss, in which there is no longer a healthcare system that serves the needs of everyone, no matter where they come from or how much they do or don’t earn.

Don’t get me wrong! We should absolutely use medication to its fullest use for those who are at risk and have not responded to major lifestyle changes. For example, we can wage war on Atrial Fibrillation, ensuring far more appropriate use of anticoagulation, in the most cost effective and safest way, therefore preventing many life-changing strokes in the mean time. And for those who, despite lifestyle measures, still have a high blood pressure or continue with diabetes, we should not withhold medication that would prevent major issues later on. It’s just at the moment, we’re reaching for the prescription pad too readily and not looking to reverse conditions completely before they set in. We need more education out there around the early signs of cancer, so we can hit it early and reverse it’s effects when we have a better chance. Respiratory disease is another area where we could seriously make a change. We need to think of ourselves as one big respiratory team, tackling smoking, housing damp and carpeting, whilst ensuring every person has an understanding of their condition, how to use their medication effectively and what to do when things flare up. A cohesive clinical community really could deliver something special in each of these disease areas.

We could also be a great deal more effective in how we care for the frail elderly. We don’t need anywhere near as many hospital beds. We can provide care in residential and nursing homes, avoiding double payment for beds, by shifting resource out of our acute hospitals and into the community. We need to have a far more grown up conversation about why we admit people to hospital when there is very little proven benefit of doing so.

Taking a strategic shift towards a social movement for health, significant lifestyle changes and treatment only after these things have been given serious attention, but unapologetically so once they have, we can turn back this battle at the gates and change the health of this nation for generations to come. We can undo the unaffordable situation we find ourselves in and discover together a much more healthy future.

images.pngWe can absolutely do this!! It’s going to take some serious resolve and we’re going to have to withstand the fear and pressure of some pretty powerful lobbies, like the sugar, alcohol, tobacco and pharmaceutical giants, and perhaps even the government itself, but it is time for us to do the impossible. With love, hope and faith, we can do this! Yes we need to focus on schools and work places. Yes, we need to partner with organisations we’ve never worked with before. Yes, we need a far more effective media strategy and yes, we need to allow clinicians to work very differently. But we cannot do nothing. So let’s try something a whole lot more radical. That’s what we’re going for in Morecambe Bay – not just better care together, but better health together – you can watch and wait, and see if we sink or swim, or you can join us!

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