Creating a Culture of Excellence

This is the 3rd in a 3-part series on how we can create great working cultures. Culture eats strategy for breakfast. The first two vlogs were on joy and kindness; this one focuses on excellence. If we don’t get culture right, we don’t get care right – and in the NHS, that is fundamentally what we are about. This one comes with a health warning! If we try and only build a culture of excellence, without first building a culture of joy and kindness, we will create a very unhappy working environment with low morale and poor quality. Excellence is built on joy and kindness!!

 

 

 

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Population Health – The Pentagon Approach

Here in Morecambe Bay, thanks especially to the excellent work of Marie Spencer, David Walker, Jane Mathieson, Hannah Maiden and Jacqui Thompson, we have together developed a way of thinking about population health, which we call the ‘Pentagon Approach’. It draws on learning over a number of years from Public Health England and the World Health Organisation, and synergises nicely with the vision and approach of our excellent Directors of Public Health in Lancashire and Cumbria. It forms part of our overall population health strategy, which I want to give some focus to over a few short blogs. In this blog I will focus on the Pentagon and what we mean by each bit of it!

 

 

 

Population health means different things to different organisations, groups and individuals. However there is agreement that population health is determined by a complex range of interacting factors e.g. social and economic, lifestyle, access to services, including health, as well as our genes, age and sex.

Most of these factors lie outside of the health care system but have significant impact on individual and population health. Lord Darzi recently wrote in the 2016 WISH report (https://www.kingsfund.org.uk/publications/articles/healthy-populations) that we have talked about making a difference to population health for decades, but no-one has really grasped the nettle to make the changes we need to see, particularly around health inequalities. Responsibility for addressing these issues are fragmented. Therefore we need to ensure that we work with a multitude of partners to:

  • Understand the problem and set clear goals for improvement
  • Focus on the determinants of health and not just health care
  • Generate shared accountability
  • Empower people and communities and develop their capabilities
  • Embed health equity as a core element.

Therefore Population Health in Morecambe Bay is defined as:

The health outcomes of our citizens as a group, including the distribution of those outcomes across the geography of Morecambe Bay.”

In Morecambe Bay, we have developed a way of thinking about Population Health through the means of five key strands, namely – Prevent, Detect, Protect, Manage and Recover.

Various definitions currently exist around these words, but in Morecambe Bay, the definitions will be used as follows:

Prevention

Prevention means preventing disease or injury before it ever occurs. This is done through:

  • Working with communities and other partners to tackle the underlying social determinants of health (e.g. living and working conditions, social isolation, health literacy etc.)
  • Encourage the development of health in all policies
  • The promotion of positive behavioural choices which improve a person’s health and wellbeing (e.g. stop smoking, reduce alcohol, take regular exercise, eat healthily)
  • Preventing exposures to hazards that cause disease or injury (e.g. through hand hygiene, health and safety )
  • Increasing resistance to disease or injury, should exposure occur (e.g. immunisation programmes)

Prevention can be primary (before a diagnosis) or secondary (after a diagnosis), but always refers to creating an environment that supports healthy choices, lifestyle changes, rather than medical intervention.

Detection

Detection means early recognition that:

  • a person is developing increased risk factors which may predispose them to a more serious condition (e.g. obesity, rising cholesterol, high BP, low mood)
  • a person has developed a chronic condition, for which they will need further protection (e.g. COPD – chronic obstructive pulmonary diease, Type 1 Diabetes Mellitus)
  • a local population are more at risk of developing a particular condition/set of conditions (e.g. detection of childhood obesity rates, high rates of smoking, high rates of alcohol use, poor housing or air quality )
  • a local population has worse health outcomes than another, requiring appropriate resource allocation (e.g. poor cancer survival rates, high rates premature mortality, low access to preventative interventions)

Protection

Protection means:

  • to protect someone from developing a condition of which they are at risk, through medical intervention (e.g. starting antihypertensive medication) – this would also go hand in hand with some further prevention measures
  • to reduce the impact of a disease or injury that has already occurred (e.g. ensuring protection after a first MI of having a second MI through strict treatment of BP, cholesterol and kidney function, smoking and dietary advice)
  • to soften the impacts of an ongoing illness or injury that has lasting effects (e.g. helping a person to understand a chronic condition they are living with, through structured education and ensure best evidenced treatment, to help them live at optimal health)
  • to protect someone from developing a more serious condition, through surgical intervention (e.g. prophylactic bilateral mastectomy)

Management

Management means:

  • to provide appropriate advice, treatment or referral for a single episode of a health complaint (e.g. minor ailments )
  • to intervene at the time of a medical or surgical emergency with best evidence-based practice (e.g. transfer to a cardiology centre for management of a STEMI – [heart attack])
  • to treat an exacerbation of a chronic condition through a best evidence-based intervention (e.g. an acute exacerbation of COPD)

Recovery

Recovery means:

  • helping people manage long-term, often complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life and their life expectancy (e.g. through cardiac/pulmonary rehabilitation, community integration, support groups, social care provision, vocational rehabilitation programmes, links to financial advice)
  • recognising where people will not recover and enable good palliative care and a good death

This Pentagon describes our ‘population health approach’, but is not the complete picture of how we think about population health. More on this in some follow up blogs and vlogs.

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Creating a Culture of Kindness – Vlog

Here is Part Deux of my 3-part Vlog series on how we can create great culture in Health and Care Systems (or anywhere really!).

 

“Culture eats strategy for breakfast,” Peter Drucker, but I don’t think we believe this anywhere nearly enough!

 

 

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Creating a Culture of Joy – Vlog

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Facing Our Past, Finding a Better Future – Adverse Childhood Experiences

This week I had the privilege of listening to Prof Warren Larkin, advisor to the Department of Health on Adverse Childhood Experiences. This is something I’ve written about on this blog before and Warren has made me more determined than ever to keep talking about this profoundly important issue. This blog draws on his wisdom and learning.

I believe that Adverse Childhood Experiences are our most important Public Health issue. So I want to be really clear about what they are, how and why they affect us so deeply, where we can find help if we’ve been affected by them and how together we can change the future, by preventing them.

 

What Are Adverse Childhood Experiences?

 

• Physical abuse
• Sexual Abuse
• Emotional Abuse
• Living with someone who abused drugs
• Living with someone who abused alcohol
• Exposure to domestic violence
• Living with someone who was incarcerated
• Living with someone with serious mental illness
• Parental loss through divorce, death or abandonment

 

How Common Are They?

 

The answer is – far too common. There have been some really wide ranging studies across the UK and USA into the numbers of us who have experienced ACEs, and it’s not just in our “most deprived communities” but in predominantly white, middle class areas where we see the stark statistics. Depending on the study you read, between 50 and 65% have experienced at least one ACE. And shockingly 1 in 10 of us have experienced more than 4.

 

How and Why Do They Effect Us?

 

Firstly, they affect us by quantity. The more ACEs we experience, the worse our physical, mental and social health and wellbeing is. If you have experienced one ACE, you have an 86% chance of being subject to several. If you experience more than 4, your health and wellbeing is significantly affected. If you experience more than 6 then you have a 46 times higher chance of becoming an IV drug abuser, a 35 times higher chance of committing suicide and an overall 20 year decrease in life expectancy.

 

Secondly, the toxic stress levels significantly change the way in which our brains grow and function. This has a profound impact on our day to day functioning. ACEs are a massive cause of absenteeism from work, high cost to the health and social care system and highly predictive of time behind bars. That is why so many of us have complex relationships with things like food. Losing weight, for example, is not as straight forward as eating less, exercising more or ending up with a gastric band. Did you know that suicide rates are massively increased after bariatric surgery? By removing the ability to eat, the very thing that takes away or comforts the pain, we expose the underlying issue, but provide no healing into that void.

 

Thirdly, our bodies literally keep the score of the negative experiences. So, we become more likely to develop chronic pain, inflammatory conditions, heart disease, cancer and mental health issues.

 

Fourthly, the toxic stress actually alters the way our DNA works and therefore changes the genetic information that we pass onto future generations. As an example, domestic violence in pregnancy is predictive of child developmental issues and offspring of the survivors of the holocaust or genocide are far more likely to develop chronic anxiety. This highlights just how important our family history really is.

 

Fifthly, there are proven things we can do a) to help our brains learn how to cope in the midst of really difficult circumstances (resilience) and b) therapeutic interventions that can genuinely heal us.

 

Where Can We Find Help?

 

Here’s the thing – this is where the rubber hits the road.

 

Many of us, who have experienced difficult things in childhood/adolescence never talk about them. Sometimes that’s because we can’t remember the experiences – they happen to us before our memories fully form. But perhaps more frequently we bury them because we don’t want to talk about the deeply painful memories, we don’t know how to or we’re worried about what might happen to us, or the people who caused us the pain if we do. And how do you start a conversation like that anyway? What? Are you going to just blurt it out to someone? And what on earth will you do if you just start crying in the middle of a restaurant when you talk to your girlfriend/boyfriend about what happened to you? And what about all those complicated associated feelings of shame, guilt, fear, thoughts of rejection? So…..we keep the lid on….even though it’s to our own detriment because we don’t know how to bring it into the open.

 

And here in lies the starting place. It’s vital that we learn this in the world of health and social care, but actually we all need to hear this incredible truth. Various studies have shown that it takes 9-16 years for people to be able to talk about trauma/abuse they experienced, but most never do. Fraser and Read found that in their patients struggling with mental health issues, only 8% of them volunteered that they had experienced ACEs. However, when they were actually asked about this, 82% then talked about ACEs they had experienced. So? So, we find it almost impossible to talk about, but when someone asks us about what we have lived through, it takes the lid off the box, peels the sticky plaster off the deep wound and allows us to begin talking about our pain. And here’s something really remarkable……Felitti and Andra found in a study of 140000 people that simply by routinely asking all patients about ACEs, they saw a 35% decrease in visits to the GP and an 11% reduction in use of the Emergency Department!

 

What does that mean? It means that giving someone the chance to talk about their journey, what they have been through, breaking the cycle of shame, fear and rejection is, in and of itself, deeply healing! Knowing that you’re not a freak, knowing that it wasn’t your fault, knowing that it doesn’t mean that you yourself will become an abuser/alcoholic/poor parent and many more realisations can make a significant difference to a person’s wellbeing. Maybe it doesn’t have to wait for a GP’s surgery or a counsellor’s chair. Maybe, just maybe if we all care enough to ask each other deeper and more caring questions we can help to heal each other. I know this is true of my own journey and that of many of my friends.

 

But let’s not be naive. For some of us, the experiences we have had are so horrific that we are stuck in a moment and we can’t get out of it. And this is where good therapy really comes in. I wonder if we invested more in therapy and less in drugs to numb our pain, how much more healed we might be – perhaps more expensive in the short term, but overall the cost is far less, both for the individual and society as a whole. There is help available and it can take many forms. EMDR, Trauma Focussed-CBT, Bereavement Counselling and even things like working through a forgiveness process. Unfortunately, many of the waiting lists are very long, and private options are way too expensive for most people to afford.

 

So, Can We Change The Future?

 

You know that I believe together we can! But it’s not going to be easy, especially not in the context of our floundering social services, restrictive school curriculums, reduction in numbers of health visitors and school nurses, eye watering cuts to public health budgets and significantly stretched CAMHS and Adult Mental Health Teams. And I think we have to very real and honest about that, because if this is such a massive issue in our society (and the data and evidence is astounding) then we need, as Warren Larkin so eloquently argues, genuine commitment from leaders and organisations to shift towards a culture of learning and collaboration to bring about change.

 

Here are some things we need to do together:

 

1) Own up to what a massive issue this is.

2) We need to learn how to ask our friends better questions and care enough to listen to each other’s experiences and journeys because it is really hard to know how to start talking about ACEs, but is more possible when someone bothers to ask!

3) We need to recognise that by bottling things up, we do further harm to ourselves. Perhaps some of our complex addictive patterns of behaviour, our mental health issues, our physical pain and symptoms might well be linked to the ACEs we have experienced. So maybe we don’t need a life on painkillers, cigarettes or with a complex addictive behaviour patterns. Maybe we can find a way to deeper healing.

4) In health and social care, we need to adopt REACh (routine enquiry about adversity in childhood) – we need to change the way we take histories from patients and ask better questions. Remember that even by asking, it doesn’t open up scary and messy consultations that we don’t have time for, actually it opens up a therapeutic space which can massively alter how a person goes on to use the health service in the future.

5) We need to ensure schools are more vigilant to thinking that ‘naughty’ or ‘difficult’ children are actually highly likely to be in a state of hyper vigilance due to stressful things they are experiencing at home. Expecting them to ‘focus, behave and get on with it’, is not only unrealistic, it’s actually unkind. Simply recognising that kids might be having a really hard time, giving them space to talk about it with someone skilled, teaching them some resilience and finding a way to work with their parents/carers via the school nurse/social worker could make a lifetime of difference. It is far more important that our kids leave school knowing they are loved, with a real sense of self-esteem and belonging than with good SATS scores or GCSEs. The academic stuff can come later if necessary and we need to get far better at accepting this.

6) Parenting classes should not just be for the well-motivated or struggling. They should be for all of us – a routine part of antenatal care and alongside our children’s education and include help in dealing with previous ACEs, so they are not repeated for the next generation. Prevention is possible. And that means we need to learn to be a whole lot less judgemental and a great deal more open, honest, vulnerable and restorative with each other. One of my best memories of growing up, was going to a “foster home” for families that my mum used to work with and seeing parents being given the chance to learn how to love their kids, rather than have them taken off them. I know sometimes there is no choice, but helping people learn how to be family and to love and cherish their children is a really beautiful thing. When there has been generational abuse, it is is also of the upmost importance. I’m not saying that a child should never be removed, but we can hardly say that our care system is a rip-roaring success story.

7) We need to find a way of working with men and women in our prisons that enables them to find a way to healing and restoration, not retribution for what are often extremely complex stories.

8) We must learn from best practice around the world. For example, did you know that the vast majority of paediphiles begin offending at the age of 14?! Most of them do not go on to become prolific offenders, but the damage caused to the child they abuse is obviously significant. There is some amazing work now going on in Pennsylvania which has shown that you can actually prevent young men from becoming offenders in the first place. Simply by doing some better sex education, explaining to boys about testosterone, the urges they are having and who it is appropriate to perform sexual acts with; alongside creating a really safe space where they can come and talk about feelings they are having (a bit like AA – with no ridicule or judgement) – data shows that you can decrease the incidence of child sexual abuse. We have to learn from this kind of approach and find a better way of talking about difficult issues. Prevention IS possible!

9) We need to find a way to fund more psychological therapies and become much less reliant on drugs to numb the pain with the associated colossal bill paid to Big Pharma.

 

 

This is an area I am really passionate about. I am committing to keep this conversation alive, to ensure that we make a shift in our organisations towards a REACh approach, to find a deeper and more effective partnership with colleagues in education, social services and the police and to create space for more training and awareness for all our staff teams. I know how painful this conversation is, but I also know how utterly damaging it will be if we don’t change the future and prevent this from being a perpetual story through the generations. It is time for the hearts of the elders to turn to the children. Together we can reimagine the future. Together we can.

 

 

Here is a really helpful film:

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Never Let a Good Crisis Go to Waste

So, the NHS is in another winter crisis.

The Oxford English Dictionary defines a crisis  as:

1 A time of intense difficulty or danger.
‘the current economic crisis’

Mass noun ‘the monarchy was in crisis’

1.1 A time when a difficult or important decision must be made. As modifier ‘the situation has reached crisis point’
1.2 The turning point of a disease when an important change takes place, indicating either recovery or death.
Origin
Late Middle English (denoting the turning point of a disease): medical Latin, from Greek krisis ‘decision’, from krinein ‘decide’. The general sense ‘decisive point’ dates from the early 17th century.

 

A crisis is still a crisis, even if you see it coming. What is vital, as per Winston Churchill, is that a) we don’t waste this moment, but allow it to be a true tuning point and b) we don’t rush prematurely to actions to try and solve it, but ensure we look deep enough and far enough and then move towards collective steps for an altogether different kind of future.

 

I think there are some difficult and inconvenient truths that we need to face up to together. If we can do so, then we can move beyond sensational news cycles into co-producing something really exciting. Here are my incomplete thoughts about where we might want to think about starting:

 

  1. We need to get some perspective! One of the dangers of believing everything is bad is that we start to believe that the NHS is over. It is not over. It is 70 years old and it is transitioning, but it is not over! In the crisis we find ourselves in, let’s remember why the NHS is such an incredible thing and why its integration with social care is so vital. The Commonwealth Fund rates the NHS as the BEST healthcare system in the world, when it comes to equity, care and accessibility. However, our outcomes are significantly worse than that of our peers – there are some really important reasons for this, which we need to understand better. One of the major reasons is that our goals are so short term, that we cannot bring the long term changes to the health and wellbeing that we need – and this is caused by the way the NHS is run and the nature of our political cycles.
  2. We need to stop the boring, binary, partisan nonsense that is the political boxing match. It really is grow-up time when it comes to our arguments. There are some very different perspectives on why we’re in the crisis we’re in, what we might do about it and how we should go about those things. However, shouting our perspectives ever more loudly, whilst never encountering or deeply listening to the other perspectives in the room make it impossible for us to find an effective 3rd way forward together. We are well versed in the blue vs red options, but let us be honest, please. Neither the reds nor the blues are wholly right, and neither is wholly wrong! It is absolutely OK to hold different perspectives, but the manner of our arguments is astoundingly pathetic. Whilst all this shouting goes on, there are several perspectives that are not being heard, important voices, those of the patient, the carer, the poor etc. We need to stop our reactionary, swing left, swing right steering of this great ship (and that’s not to say a centrist approach is best either!) and learn to have some humility. Humility starts with listening and being willing to change. This is being so beautifully demonstrated by the Rose Castle Foundation and Cambridge University through their work with the vastly differing world views of Conservative Islam, Judaism and Christianity and offers us much learning and hope for the NHS and indeed any other of our deeply held belief systems. Anyone willing to have better conversations and find a way forward?
  3. The maths simply doesn’t add up. We need some honesty.  A few weeks ago, the head of NHSI Jim Mackey, said that by April the NHS will be in around £2.2billion of debt. That is a very conservative estimate. It is a mathematical impossibility to close wards and scale down the size of our hospitals at a time when district nursing numbers have reduced by 28% over the last 5 years and social care is on its knees AND sort out the deficit! We know what the direction of travel needs to be, but the equation is simply unworkable, due to time and workforce pressures.We need to understand the true scale of the problems we’re facing and be real about how much money is going into health and social care spending compared to what is actually needed.
  4. The reason for this is that health and social care funding is becoming more costly and more complex. Our population is growing in size and people are living longer – this is great, on many levels (although we still need a much better conversation about death and why sometimes we keep people alive, when we could allow them to die well and peacefully). However, as we grow older, we develop more health conditions, and social needs, which require more costly treatments and packages of care, which we’re simply not accounting for, especially when we know the predictions of how our population will grow and age over the next 20 years.
  5. We therefore need to have a long term vision of how we want to build the most safe, excellent, effective, equitable, efficient, compassionate and kind health and social care system in the world whilst recognising in order to so, we will HAVE to make some upfront, BIG investments. It is simply impossible to have double austerity on health and social care and then believe we can do the transformational work necessary for the future change we need. Austerity has woken us up to the fact that there are some inefficient ways of working and some things we could definitely do more effectively in partnership. We’ve learnt that now. However, as a philosophy it is now defunct for where we need to go.
  6. This means, we have to put significantly more money into the system now. Once we have done some more work on the vision and plans for the future (the 5 year forward view is too short and although sets us up a good trajectory, is not ambitious enough), we need to ensure there is a sufficient injection of cash (not removal of it) to make this possible. So, we have some options available to us. A) We could increase tax for everyone – something that 67% of our population seem to be willing to pay. B) We could close tax loopholes and ensure that companies like Amazon and Google pay the tax that is owed. C) We could also increase our GDP % spend on health and social care – remember, currently, we have one of the lowest % spend of any of the other OECD nations. Perhaps a combination of all of these things is necessary.
  7. Creating long term health and social care solutions means that we have to put population and public health as the foundation of the system. We know that prevention is better than cure. We know that if we promote health and wellbeing, disease will be far from us. The disinvestment in these areas and the over reliance on a very stretched and struggling community-voluntary-faith sector is a recipe for disaster. There is huge work to be done in deeply listening to and working with our communities to improve the health and wellbeing of everyone, using the best research, evidence and data available to us through our public health bodies in order to make this shift.
  8. This means we need to continue to tackle the wider determinants of health and think radically about these things as being serious public health issues. This is how the city of Glasgow has gone about tackling knife crime and London has much to learn. We need to apply wisdom and learning to things like smoking, sugar, alcohol, pollution, drugs, road traffic accidents, domestic violence, suicide and adverse childhood experiences. We also need to develop a radically generous philosophy to the areas of job creation, housing, land rights and the care of the environment of which we are stewards not lords.
  9. We have to take greater responsibility and care of the health and wellbeing of ourselves and of those around us. It is not possible for us to have a national health and social care system that is sustainable if we think we can live exactly how we want whilst thinking someone else will simply mop up the mess or pay the tab. Our sugar, food and alcohol consumption, lack of exercise, driving, smoking and drug habits are all areas where we do have to take greater responsibility. NHS staff need to lead by example here. They are also areas where government give those lobbies far too much power and where we need better legislation to help bring about change. It is a both/and not an either/or approach.
  10. We need to create a much more shared-care approach with patients, co-partner with patients to enable them to understand the conditions they live with so that they are able to self-manage/self-care more effectively and create community support groups.
  11. We need to use digital solutions to full effect. We need to widen the access to patients having their own online records, the sharing of data across the system and getting savvy with better apps and technology for the benefit of patients and communities.
  12. We need to change our expectations of what we believe our ‘rights’ are in terms of health and social care. As an example, people phone up a GP surgery and want to see a GP. But there are MANY other allied health and social care professionals who may be better placed to sort out the problem. However, a recent survey in Gosport showed that of the people who phoned up wanting to see their GP, only 9% of them actually needed to see their GP and the rest would have been dealt with more effectively by someone else. We need to get used to the fact that we don’t have enough GPs available for everyone to be able to see one every time they would like to, but there are other professionals who are equally able to help. Another example is that everyone wants to safeguard their local hospital and we tend to have a fixed belief that being in hospital when we’re ill is the best place for us. Actually, especially when we’re older we can receive just as good care at home or in a nursing home and being admitted to hospital adds very little benefit. However, in order to have smaller and therefore more affordable hospitals, we really do have to ensure we have the necessary infrastructure and staffing around community nursing, social care and General Practice. Currently this is not the case and it takes time and investment to grow this workforce.
  13. We need ensure we are training and recruiting the right skill mix of people for the right jobs. This means we need to think at least 20 years ahead with the predictive statistics we have available to us and do some proper workforce planning. We’re are far too short sighted. This will take financial investment now, as stated above, but if we get it right, will leave us with a far more effective and efficient living system in the future.
  14. Our medical, nursing and therapeutic school curriculums therefore need to ensure they are training students for the kind of future we need. We need a complete redesign of some of the curriculums and we need to change the way training is done. As part of this, we need to ensure we are raising good human beings, not just good professionals, with values, culture and great communication skills built into all of the process.
  15. We have to redesign the contracts, as unfortunately without this, some of the behaviour changes simply will not happen. The current contracts across health and social care are the very antithesis of what is needed.  This will take some bravery and leadership, but it is time to grasp this nettle. Without this, we will behave perversely because the incentives driving the system and the nature of competition laws are detrimental to the collaborative future we need.
  16. We can only do all of this together. This means our staring place in all of this is to own up to the fact that in all of the above, we simply don’t know. From the place of not knowing, we can ask great questions, bring our bits of expertise to the table and build a jigsaw. There is expertise in national and local government, but certainly not all the answers. There is expertise in the health and social care clinicians, practitioners and managers. There is expertise in our communities and with people who have lived experience of the various complex issues we face. It is only together that we can face the future. Let’s break out of our camps, our deeply entrenched belief systems and find a new way of dancing together. The future belongs to us all. Together we can.

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Lessons From Helsinkii

I’m just returning from 36 hours with the Coalition of Partners for Europe, as part of the World Health Organisation. There were a further 2 days of conversations to occur, but I needed to get back to Morecambe Bay. I have learned so much during my short time with this amazing group of people, some new things and other things learning at a new depth or from a different perspective. I am again bowled over by how using tools from the Art of Hosting can bring a diverse group of people, across languages and cultures together to have really important conversations. Rather than write this in long paragraphs, I’m simply going to bullet my learnings, some of them personal, some more corporate, some amusing, some difficult. One thing is for sure: I know much less than I thought I knew!

1) Finland is 100 years old this year. It has a fascinating history. They also have one of the best Public Health systems in the world and are huge at tackling the social determinants of health. We have much to learn from them and their Scandinavian neighbours.

2) People LOVE the idea of a Culture of Joy! There is a tiredness to the WHO but a recognition across the board that there is a need for cultural change and that culture determines an enormous amount in terms of how well organisations function. Remember a culture of joy is built on good, honest, open, encouraging, kind, approachable and vulnerable leadership, with team members feeling a) that they belong and are loved/valued b) that they are trusted to do their work and c) they share a strong sense of vision.

3) There is wide recognition that Social Movements are vital if we are going to break down health inequalities and see the health and wellbeing of all people improve. We simply cannot come up with ideas in board rooms and ‘do them’ to communities. However, there is also fantastic data and learning available to communtities, which can fuel the social movement. Public Health and Primary care must not sit as separate to or aloof from this emerging movement, but must be a key player and protagonist.

4) When dealing with complex systems, it is good to think of them as gardens instead of machines. To whom does the garden of public health belong? Public Health belongs to the public – it is part of the commons. Therefore communities need to be more involved. There are some great examples of community engagement from across Europe. However, we must move from consultancy to co-production and co-design.

5) Helping people live longer at a poorer quality of life is a pointless goal. The league tables and goals we develop must be co-designed with communities. Our markers of health and wellbeing need some reassessment.

6) People everywhere in the Western world are scared of talking about death and this has huge implications for how we spend money in our health systems.

7)  Our European history is so fragile. This causes its own complexities when European people meet together – it all comes into the room with us and requires grace and kindness as we communicate. The quality of relationships within the coalition is fantastic, but more time is needed to develop this.

8) When trying to drink a yoghurt in a taxi, it is important to seal your lips around it well, otherwise you spill it all down your front and look like an idiot.

9) Public health and Primary Care are the bedrock of any health system. I knew this already, but the evidence from around the World is staggering. If these two foundation stones fail, and the staff who deliver these services are not cared for, the entire system collapses.

10) The UK has some of the best public health systems of anywhere in the world. However, the world is watching the decimation of our public health services with dismay. The vital role of prevention and protection that public health has must never be underestimated. If we do not invest in prevention, the consequences for the health system is devastating. The reorganisation of Public Health into our county councils has seen profound cuts to the budgets, as councils have removed the ring fenced budgets. This will almost certainly have detrimental consequences, especially when it comes to tackling our most difficult health and wellbeing issues.

11) When people tell you that all saunas are naked, this may not actually be true and you might end up feeling pretty awkward!

12)  We have much to learn from other areas and nations. Shared learning is key. We can do this without competition, hierarchy or lording it over each other.

13)  Building good relationships is everything.

14) There is a new generation of leaders emerging who are able to deal with complexity, refusing old silos, borders and hierarchies and finding ways to collaborate through good, honest and vulnerable relationships.

15) We need to learn to hold expertise in one hand and humility in the other. The expertise in epidemiology and the mapping of our health and social issues is vital, if we are going to close the health inequality gaps.

16) Public health is dependent on building partnerships. The wider social determinants of health (poverty, housing, adverse childhood experiences, loneliness, education, environmental issues etc) cannot be tackled by the meagre Public Health budgets. Coalition, collaboration and cooperation across many sectors are necessary for us to begin to tackle these hugely complex social justice issues.

17) Due to public health being underfunded, it leaves it wide open to abuse from those who hold the money strings. Lobbies, donors and national governments hold huge power in determining what does and does not receive funding, often despite the evidence.

18) We need leaders who understand the importance of gift economy and making investments into areas which will not serve their ego nor their profile, but will cause huge benefit to many people.

19) Collecting really good data is important. We need to learn to use it well to shape the conversations and change policy and legislation.

20) Public health holds a hugely important voice in calling governments to account for policy decisions that are to the detriment of a nations health. There is now clear evidence that austerity economics is really bad for people’s physical and mental health and is actually causing people to die. Theory must be challenged hard when evidence does not support it.

21)  The poverty truth commission has so much to teach us. No decision about me, without me is for me. this statement made a profound impact on some of the delegates.

22) Doughnut Economics has caught the attention of the coalition.

23) Fazer chocolate is delicious.

24) One of the most challenging truths I learned is that it is often public health workers and doctors/clinicians working on the front line, who are the biggest barriers to working differently with communities and ironically get in the way of the very thing they would love to see happen. This has more to do with the ways we train people to think and work than anything else.

25) Although my talk went well and was hugely well received, I am learning more about the power of story and how to tell our story more effectively.

26) I am grateful that the coalition of partners does not depend on membership of the EU but I am more aware of the pain that Brexit is causing both for me personally and for many friends across Europe.
I understand that Brexit is happening, but day by day it feels to be one of the worst decisions we have ever made as a nation. It is going to cost us over £50 billion to leave, cause untold issues for our ability to trade, decimate the 3rd sector (which btw is the only thing right now stopping our public services from completely collapsing), undo so much great work built through the partnership of our nations and not deliver on any of the false promises made around extra money for our health system or solve our ‘migration issue’. Yes, the EU needs to change, but we have made a monumental error in leaving, rather than reforming it and I still feel we should just apologise and rebuild our bridges rather than burn them.

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Health Spending in The North vs The South

A few months ago, I wrote a couple of blogs exploring the social justice issue that is the vast difference between the health spend in the North, compared to the South.

 

This week a graph was produced by HM Treasury to show how overall spending has changed across England since 2012. Here is the evidence:

 

 

So, in the North, we already have the worst health outcomes in England with an underspend of around £800m per year, per head of population, compared to the South. Yet, over the last 5 years we have seen further disinvestment here at a time when we’re also being asked to make substantial savings! Why the Northern MPs do not seem to think this is worth making much noise about, I’m not quite sure. This is an economic issue, a political issue, a social justice issue and a humanitarian issue. As I take the conversation to our public about the difficult choices ahead of us, here in Morecambe Bay and Lancashire over the coming months, I wonder what the response to this information might be?

 

 

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Speed

Here is a beautiful piece of prose that I have found really helpful over the last year – well worth a read and some time to reflect:

 

SPEED

 

Speed has compensations.  Speed gets noticed.  Speed is praised by others. Speed is self-important.  Speed absolves us.  Speed means we don’t really belong to any particular thing or person we are visiting, and thus appears to elevate us above the ground of our labours.  When it becomes all-consuming, speed is the ultimate defence, the antidote to stopping and really looking.

 

If we really saw what we were doing and who we had become, we feel we might not survive the stopping and the accompanying self-appraisal. So we don’t stop, and the faster we go, the harder it becomes to stop.  We keep moving on whenever any form of true commitment seems to surface.  Speed is also a warning, a throbbing insistent indicator that some cliff edge or other is very near, a sure diagnostic sign that we are living someone else’s life and doing someone else’s work.

 

But speed saves us the pain of stopping; speed can be such a balm, a saving grace, a way we tell ourselves, in conscious ways, that we are really not participating.

 

The great tragedy of speed ….is that very soon we cannot recognise anything or anyone who is not travelling at the same velocity as we are…….We start to lose sight of the bigger, slower cycles that underlie our work.

 

We start to lose sight of family members, especially children, or those who are ill or infirm, who are not flying through the world as quickly and determinedly as we are.
 We forget that our sanity is dependent on relationships with longer more patient cycles extending beyond the urgencies and madness of the office.

 

A friend falls sick and in that busyness we find their interruption of our frantic lives frustrating and distracting. On the surface we extend our sympathies, but underneath we are already moving in a direction that takes us far away.  We flee the situation even if we are sending flowers every day; we rejoin, thankfully, the world that is on the go, on the move, untouched by mortality.

However, through whatever agency it arrives in our lives – a broken limb, the loss of a loved one, the collapse of our business, a moment of humiliation in the doorway of a meeting room – our identities built on speed immediately fall apart and disintegrate.  We find ourselves suddenly alone and friendless, strangers even to ourselves.

 

David Whyte “Crossing the Unknown Sea”.

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Creating a Great Culture – Part 2

In the last blog, reflecting on the book “Legacy”, by James Kerr, I started to explore how the All Blacks have managed to create such an excellent culture; reflecting on what we can learn from it in the health and social care system (or indeed any environment).

 

Of the 15 principles outlined, I looked at the first 8 (the pack) and now I will look at the back 7.

 

9) Stay Focussed under Pressure – The eighth principle is to practice under pressure and learn to keep a cool head. This ninth one is about individuals and the team keeping their focus and attention on the task in front of them when the pressure comes. There are times when the stress is on. We are hard pressed from every side. The powers are breathing down our necks, the crisis is in front of us, we feel under resourced, over stretched and at the end of ourselves. Keeping our heads, and not losing them at such times, is the mark of a team who know how to manage themselves and take care of each other. This is really about learning to be mindful, to be present in the moment and to centre ourselves well. At times of real pressure, psychologists recommend three key things: 1) Slow your breathing down and focus on the breath flowing in and out of your body – this calms the mind and brings you into the present. 2) Find a repetitive action, like tapping your foot, scrunching your toes or clicking your fingers to help your body connect to the moment you are in. 3) Rehearse some mantras, which you can repeat back to yourself, over and over, to remind you of the basic things you need to do. That is what we use ABCDEF for in resuscitation – it’s why we need the automatic pilot. It also makes us far less likely to snap at team players and hurt relationships when the proverbial hits the fan.

 

10) Authenticity – the best leaders stay true to their deepest values, no matter what situation they find themselves in. Honesty = Integrity = Authenticity = Resilience = Performance. Be taken at your word. Say what you mean and mean what you say. Be true to who you are, no matter where you are. To be lovely at work and a terrible person to your spouse or family lacks integrity and authenticity. Good people make good leaders.

 

11) Sacrifice – now, I would offer a word of caution here. We work in environments in which sometimes we sacrifice our own wellbeing or our own marriages/families due to the pressures and expectations that we put ourselves under, because we are good hearted people who often have the need to be needed or the need to be heroes. However, there is definitely a balance, because without some sacrifice and having the kind of love, which as Thomas Jay Oord puts it, is “self-emptying and others empowering” we will lack something vital in our culture.  Buckminster Fuller says we must wrestle with these questions: ‘What is my job on the planet? What needs doing, that I know something about, that probably won’t happen unless I take responsibility for it? What extra mile will make us extraordinary?’

 

12) Language – Sing your world into existence. I hosted a conversation  in Morecambe recently, in which I shared that I often sing to places as I drive or walk through the streets (weird, I know!). But I asked everyone there, that if they were to sing a song to Morecambe, what that song would be. There was nobody without a song! Leaders are storytellers. All great organisations are born from a compelling story. Words and values really matter. Organisations need their own vocabulary, mottos, mantras and metaphors. The food of a leader is knowledge and communication. In Morecambe Bay, we are beginning to develop a language and a narrative around ‘The Bay Way.’ We want our vocabulary and our dialect to reflect the vision, values, culture and behaviours here.

 

13) Ritual – now, it might be pretty awkward if we all started to try and do the Haka at the start of our meetings! Not only would be awkward but it would make little cultural sense! Even for the All Blacks, the Haka has had to change. The team is no longer predominantly Maori, but a mixture of many cultures. They have had to go on a journey together of how to keeep and adapt a ritual that really means something and connects the team together. Ritual makes the intangible real. It can take many different forms, but it really is vital. It might be a daily team check in, but my sense is that it takes some bravery to establish and continue. In the West, we are so much more detached from our sense of corporate history and identity. Perhaps we feel embarrassed about it or no longer know what it means for us now. What might ritual look like in our work places and teams now? There is a Maori phrase which says: “Tell me and I’ll forget. Show me and I may remember. Involve me and I’ll understand.” This is why I am so keen for our teams to experience things together, like the Art of Hosting. It is in the partaking, the encountering of the ‘other’, the immersion in the experience in which we find ourselves changed.

 

14) Whakapapa – this is the principle of being a good ancestor. What are you sowing into those around you. The All Blacks make it really clear that becoming an All Black is a privilege not to be taken lightly. When you receive the jersey, it comes with a weight of history and a responsibility that you take it to the next level. The challenge is not to aim for something nice to be written on your grave stone, but for your fingerprints to be left in the lives of those around you, so that the thread of your story is continued. Here are some good words: Care for the land, care for the people. Go forward. Grow and branch forth for the days of your world.

 

15) Legacy – This is your time. What will you do with it? What will your legacy be?

 

There is so much to reflect on in the chapters of this book. We are in danger of rearranging the systems in which we work, without dealing with the issues of the heart. I will keep on saying this: Culture is vital. If we do not get our values and our culture right, we build on very shaky foundations and our house will not stand. Taking the time to reflect and build our culture together will enable us to create a legacy for the future that will be beautiful and life giving.

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