Integration and Collaboration

In my opinion there are two main systemic barriers to providing great health care on the NHS, currently (there are other ones also but in terms of the system itself – these are the two biggest). The answer to overcoming them btw is not privatisation via the TTIP. I like to look for solutions to problems, rather than focus on the negative….

So, firstly (and it really isn’t that hard to do, it just requires some funding, which in the medium/long term would be money seriously well spent):

 

iuAmalgamate patient electronic records and share them across the system. There is so much time/money wasted and clinical errors made because of this very easy to solve issue. I’m sure there are reasons why citizens may feel concerned and I really do understand them, but given the great work already going on in Tameside at the hands of the excellent, Dr Amir Hannan, and the positive feedback from patients, this needs to rolled out as far and wide as possible.

It helps patients feel more able to manage their own health conditions and ensures notes are always available at each consultation. It means medication changes are managed more safely and effectively and information is shared between professionals in a timely way.

 

And secondly:

iuBreak down the silo mentality and reality of the various care organisations. Breaking down the walls that prevent effective team working and amalgamating the budgets of health and social care will be a huge breakthrough for care. We are already seeing this with the establishment of Integrated Care Teams within general practice. The teams comprise of: GPs, Community Matrons, District Nurses, Community Therapists, Midwives, Health Visitors, Mental Health Teams, Social Workers, the Police, the Fire brigade, and a Care Co-ordinator to pull it all together. If you also throw into the mix third sector organisations aligned with practices and patient volunteers, you have an amazing force for good!

 

There are some warnings to put in place. Manchester, which is the first place to really try this under ‘Devo Manc’ is having a huge overall budget cut (20%) as it launches into it. The hope is that by working more collaboratively and in an integrated way, savings will be made. But the ‘Save our NHS’ group have some major misgivings.

 

 

If you wanted to know more about the details of DevoManc and the health impacts of that. You can find the Memorandum of Understanding here: http://www.nhshistory.net/mou%20(1).pdf and the Five Year Forward View here: http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
Innovative collaboration and integration of our health and social services does not have to mean the privatisation of them. But if the TTIP comes into effect, despite huge public opposition, then the NHS as we have known it will be over. IMO the TTIP deserves a full referendum by the people of Europe. If you don’t know about the TTIP, you need to, and you should seriously think about writing to your MEP to tell them why this deal needs to be stopped.

[1] Independent: What is TTIP? And six reasons why it should scare you:
http://www.independent.co.uk/voices/comment/what-is-ttip-and-six-reasons-why-the-answer-should-scare-you-9779688.html
Huffington Post: Corporate Courts — A Big Red Flag on ‘Trade’ Agreements:
http://www.huffingtonpost.com/dave-johnson/corporate-courts—-a-big_b_5826490.html
[2] MEPs will be voting on a resolution on TTIP in Strasbourg on June 10th. It’s not a legally binding vote, but what MEPs decide will send a strong message back to the European Commission about where we all stand on TTIP. If there’s enough opposition, especially to the worst parts of TTIP, it could damage the deal for good:
Euractiv: What will Parliamentarians vote on TTIP?
http://www.euractiv.com/sections/trade-society/what-will-eu-parliamentarians-vote-ttip-313845
[3] You can find out more about the European Citizens Initiative and who’s involved here:
https://stop-ttip.org/

 

If you want to, you can sign a petition here:

https://secure.38degrees.org.uk/page/s/eu-ttip-petition#petition

 

We need to continue with the kind of healthcare we actually believe in, improving it where this needs to happen, without it being stolen from those who need it most because of greedy trade deals.

 

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UK, You’ve Had a Heart Attack – How Are You Now?

MIYou might want a cup of tea whilst you read this! I often see patients a week or two after they have been discharged from hospital with a Myocardial Infarction (what we often refer to as a heart attack). In this part of my home county, once someone is diagnosed with having a MI, they are admitted to Blackpool Victoria Hospital, where an amazing team of cardiologists literally save their life by putting stents into arteries in their heart that have become clogged up. It has been a phenomenal breakthrough in medical science in the last 15 years and has revolutionised how cardiology services are configured.

New medicines are prescribed to help keep the heart and kidneys healthy and patients are reviewed to see how they are getting on. What I always love in the initial consultation following a heart attack is how reflective a person becomes. Everything in their life gets assessed and reprioritised. Key questions are asked about how much stress they have been under, and why they were living at such a fast pace whilst forgetting about what is really important – living well, relationships, love, beauty, people and connecting with the story of who they feel they really want to be for the rest of their life. It is very rare to find a person who is desperate to get back to business as usual or someone who doesn’t ask some fundamental questions about what life is for. It is possible in some of these consultations to have some of the best coaching conversations a practitioner can ever hope to participate in. Asking some questions of the patient about what they are going to change and how they are going to do so.

And yet, in the UK (and indeed the west), we suffered a heart attack beyond all proportions with the economic crash of 2008. But we have not really reflected on the major warning sign that it was to us. We have a government and financial system intent on “getting us back on track” – and I wonder to what, exactly? It isn’t that the financial system alone, just happened to have an infarction. It’s like assuming that a heart attack happens simply because of a defect in the cardiac system itself – this simply isn’t true. The crash was only a sign of just how broken our entire body is and we would do well to reflect a great deal more about how we are living as a nation and whether it gives us any real sustainability for the future of the planet and the generations to come. Our current response is not only to “get back on track” with where we were, but  to “tighten our belts” (which means to cut benefits left right and centre without regard for the dehumanisation of people in the process). It’s like believing the correct response following an MI is to emaciate and punish yourself, without asking some fundamental questions about how healthy your whole life is.

So, what about about a national health check – let’s look at each system in turn and ask some questions – because the truth is, we haven’t faced the fact that we are in an age of transition in which answers are not obvious and we don’t have any experts who have been to the alternative future we long for. So, we have to learn together and ask open questions that provoke better conversations to help us.

Let’s start with Education. George Monbiot has written a stunning piece in the Guardian about the current health of the education system: http://www.theguardian.com/commentisfree/2015/jun/09/aspirational-parents-children-elite?CMP=share_btn_fb – well worth a read. Our education secretary, Nicky Morgan on the other hand isNicky Morgan intent on more testing of our children and has recently given a speech in which she claimed that arts and humanities subject choices close down a child’s career options and they will earn 10% more in their life if they do Maths at A level – whooppee do dah. For an alternative and altogether more inspiring approach, look to the lovely Ken Robinson:

Couldn’t education become about real learning in which our children feel inspired and find hope for the future?

Ecology – Oh dear – so far a string of broken promises on the environment from the western governments. It turns out that oil and industry is more important than the future of the planet. Is it? If not, what are we going to do?

Defence – undergirding our entire nation are three things: Money as debt (see finance), the state of the exception (see law and order) and military violence. The ultimate trust of our nation rests on nuclear warheads. How healthy is this? How much fear do we have to create as a narrative to believe this is actually a good thing? Do we want that to be the undergirding faith of our nation? And what about the change in rhetoric regarding soldiers who die in war. David Cameron recently referred to soil from the battle fields of WWI (which was brought to London) as ‘Holy Ground’ and he described those who died fighting for the ‘allied forces’ as ‘martyrs’. Is the nation state therefore the ‘saviour’? If it is, what on earth do we mean by this? If not, then is there other language we can find to use about the two world wars without creating a very dangerous worldview?

Housing – 69% of the land continues to be owned by 0.6% of the population and there is a real lack of social housing available in deprived areas. This is causing significant problems for those already under huge financial strain, given the effects of austerity measures. Who does the land belong to and why?

Justice – How many of the perpetrators of crime are victims of a system that left them with little or no other choice but to commit crime? How restorative is our justice process?

Law and Order – our prisons are full to breaking, our police force is being cut and replaced with private security firms. How effective is our law and order system? And what undergirds it? Georgio Agamben cuts through to the heart of the issue in his exquisite book ‘State of Exception’. Underneath the whole of western ‘democracy’ lies the right for the government to suspend the rule of law i.e. invoke Marshall law if deemed necessary. I look at the people movements emerging across Europe right now and wonder how far we are from the ‘state of exception’ being invoked. All it will prove, as we already know, is that democracy is a vain imagination. What is it that undoes ‘the powers’? Could a movement for positive peace, founded on love offer any realistic alternative? If so, what?

Immigration – apparently the answer to our problems is to become more fearful of the ‘other’, create a politics of fear and blame immigrants for our financial problems. We are barricading our doors Syrian Refugeesand building up our walls to ‘protect our way of life’. And while there are currently 4 million homeless Syrian refugees, the UK has welcomed 147 of them in total. Did you know that the entire world population could fit into Texas? Our concerns about lack of space and lack of jobs is really unfounded and we seem willing to ‘love our neighbours’ with great initiatives like comic relief and generous charitable giving, just as long as it doesn’t actually have to affect us and our way of life…..how loving is that? How healthy is love that does not truly cost us and change us?

Health – this whole blog is about it, but 1 in every 5 pounds spent in the NHS is due to poor lifestyle choices we are making. We can’t live imgresexactly how we want if we hope to continue with a health service that is free for everybody. How will we change the culture? Can we find innovative ways of working collaboratively within the system that breaks down the silos in order to work more effectively for the good of our national health? Is privatisation the answer? If not, what are we willing to change/protest about to keep it public?

Government – a majority with 36.4% of the vote? Deeply wrong. There continues to be profound disengagement with the system and a deep cynicism that the current style of government can bring any real lasting change. We need a new politics – what might that be like? Where are the leaders who will choose to facilitate instead of dominate?

imgresEconomy – ah yes, that old chestnut. Do we want an economy in which the gap between rich and poor continues to widen? Do we want a system in which the poor are punished whilst the rich are exonerated for their greedy crimes? The entire western economy is based on a system of debt that requires us to continually grow and expand our borders so that the debt can be serviced. We have become slaves to the economic beast. Where are the alternative experiments emerging? What can we learn from them? Are we brave enough to try something new? I have posted this before, on my other blog – www.reimaginingthefuture.org  but Charles Eisenstein is so worth watching:

The human heart provides us with a great metaphor. The health of our nation(s) is not good. We’ve had the wake up call, and if we’re not careful (this is a warning from a doctor, so take heed), the next heart attack will be even more catastrophic. We have to reflect on where we are and ask ourselves where our current trajectory will lead us. I don’t want to get back on track if it leads us to more depression, destruction and decay. I want to find the road less traveled by – the one that leads to life, hope, love, regeneration, recreation and a beautiful future for our children. So many questions. So much to learn.

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A Conversation in Response to ‘Living with Illness’

After my last blog post, I got a couple of responses from people who felt I misrepresented them. I am always happy when people come back to me in discussion. We are never changed if we cannot receive challenge or we do not really encounter ‘the other’. So here is a conversation between me and a lovely person called Elly who helped me think more deeply about the complex issues of living with illness.

Hi Andy,

I’ve been introduced to your blog via Martin Scott’s, a dear friend. Interesting timing in that my daughter (in New York) and myself in the uk are both seeing consultants today looking at our multiple autoimmune diseases plus some possible new ones! We also have a group of friends praying today, as our health puts limitations on us. So here’s the thing, I read “living with” and then “are you healthy?” and got very angry….. don’t go away…. chronic illness is real, debilitating and often life threatening.. you know that. We would love to be able to function without them, sometimes it’s not possible and sometimes can mean often.

You suggest that health professionals and I would add government and well meaning charities label us disabled. I use the term disabled to get financial aid, practical help and to explain what it’s like because chronic illness doesn’t cut it for most people (they think it’s all in you head) another label. NHS and benefits don’t relate to it either. I was challenged by my use of the word and would like a creative way to describe my life (ever read the spoon theory?) My friends have been really positive with this site. Back to my anger… Maybe at myself for using the D word but also because I feel by putting us in 2 catergories you too have labelled us. We’re neither a or b (ok I know some are) but I am me, but with those limits… I’m my head I dream and sometimes wish I didn’t because trying to act on those dreams however small can bring on a crisis. I divert.. May I suggest that you too find a new way to address us?

 

are you healthy?
eating ..when we’re not nauseaous
exercising… limited due to poor mobility and pain
gratefulness… yes I am
forgiveness ..yes
care of others ….finding small creative ways to do this
nature would love to be out there too but grateful to hear the birds,watch the sky change

 

Now you may have not directed this at us but it felt like it so to try to deal with nasty feelings of mr anger I carried on listening to the amazing story of the 5th monk. (See reimagining health post). First you told it Soooo well, my attention was caught and I was totally engaged and with all that you shared. I think we will be hearing a lot more from you, you have a gift that will draw people to listen. What you say will be important (so maybe I had to get mad so I had to write to say all that (not from me).
If you want to use anything that I’ve written or you may want to delete feel free. Its been a long read admittedly or you may have given up! So bless you, continue on this journey and may others join. Use any of my stuff to encourage conversation. I’m going to get my gp reading this.
Elly

 

Wow – Elly – thank you so much for taking the time to write all of that. You are absolutely right and in my effort to write a shorter blog in which to engage people, I oversimplified it in a very unhelpful way. I was short sighted in how I communicated and probably pretty patronising as well – so for all of that I am really sorry. I guess we are only really changed as we encounter ‘the other’ and so I am hugely grateful that you took the time to tell me what it’s really like for you – it changes me.

 

 I manged to unintentionally upset another very lovely person, who told me about it on Facebook – here is part of my reply to her:
I was trying (and it seems unsuccessfully) in a shorter than usual blog to say 2 things, and I definitely didn’t unpack either well enough. However, I am hugely grateful for the chance for a conversation about it. I firmly believe we are changed as we encounter each other, and am therefore really grateful for your challenge and perspective. Gone are the days when doctors can utter edicts and always believe themselves to be right. On one level, I am trying to challenge the dehumanisation that is dealt to those, like you, who suffer with a long term, debilitating illness or disability. So much of the ‘system’ in terms of benefits, etc can (not always) dehumanise the people living with the conditions by labelling in an unhelpful way. So, I think there is a difference between calling Andy a diabetic, compared to Andy, who has diabetes or saying Janet is disabled rather than talking to Janet, who lives with a disability…..maybe I’m wrong…..
I am really hoping that we can find less dehumanising ways of talking about people who are disabled in some way…….language can be so clumsy.
 
Secondly, and this is where I was way too simplistic for which I do apologise, I was looking to speak hope rather than idealism for those who live with chronic ill health. I genuinely do touch on the deep pain and complexity of my patients lives every day and I know that the issue is not straight forward. My hope was to gently encourage without being idealistic that ones identity, although surely affected by chronic ill health, does not have to be defined by it. I have patients with debilitating MS, Parkinson’s, MND, Bipolar, schizophrenia and COPD who see their illness as part of them and they have had to courageously accept how utterly life limiting it is…..they struggle, they are breathless, they feel terrible pain, they hate, they feel hopeless at times and yet still they say that it is only a part of them – a huge part, that shapes every move they make, but isn’t the fullness of who they are. I could have said that much better…….did I improve or am I still missing it? 
 
Elly – I love what you wrote about being healthy. Doing those amazing things you do, like eating when you can, exercising in the ways you are able, being grateful, forgiving others, caring for others and appreciating the beauty around you, to me that says that although your body is suffering and tired, inwardly, you are well…..and if you weren’t there would be no judgement, only understanding (at some level) but maybe also a little offer of hope and encouragement that though the tunnel is long and dark, there would be people to walk through it with you……
Thank for your lovely encouragement to me also – I am hugely glad that you wrote to me and for the challenges you brought.
Andy

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Living Well with Illness

In my experience with patients I find two broad categories of people who live with chronic ill health (be that back pain, a life limiting condition like MS, COPD/Asthma/Diabetes whatever).

Firstly, there are people who refuse to be shaped by their illness. They remain robustly determined that the illness will live with them but they will get on with life. It has become my conviction as a result, that you can have chronic ill health, be that physical or mental and still be well.

Secondly, there are those who are defined by and shaped by their illness. Some of this is the fault of the medical profession who label people according to their illness. In my last practice, we had a great policy (especially championed by one of our amazing nurses, Irene) that we would never talk about anybody as a ‘diabetic’ or an ‘asthmatic’. Rather we talked about a person who also happens to have diabetes or asthma. We wanted to define the person not the illness. But often people end up being wrongly defined and it hugely affects the way they live.

In these conversations about reimagining health, I want to recognise that 18 million people in the UK live with a chronic condition of some sort. So, if you are one of those people, my question is this: Are you living well with your illness or is it completely defining you?

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How Healthy Are You?

imgresAn NHS health check is available to all 40-74 year old citizens of the UK. The idea is to detect problems like hypertension, (pre)diabetes and the risk of heart disease early so that preventative measures – lifestyle changes and possibly medication – can be offered in good time.

 

There is plenty of debate in the public arena as to how helpful and effective they are and also questions about what is the driving force behind them. (If you’re interested you can read more by searching NHS health check evidence base).

 

There is actually some pretty good evidence that they are making a difference. They have actually been a pretty helpful resource in helping practice nurses and GPs have ‘coaching’ conversations with people about their physical health and what they could do to improve this and help them stay healthier in the future.

 

Ken WilberHowever, does a Q Risk score (something that tells you how likely you are to have a heart attack or a stroke in the next 10 years) really measure how healthy you are? What does it mean to be healthy? If we take Wilber’s work on health and well being (1997), physical health is only a part of what it means to be truly well. If we are to embrace a more holistic understanding of what it means to be healthy people, who live in healthy communities which are part of healthy towns and cities, then we need to take a much wider view of how we measure this.

 

So how healthy are you. Starting with the physical – how is your diet and exercise? How much responsibility do you take over the substances you put into your body – alcohol, cigarette smoke, recreational drugs, sugars, caffeine, toxins like aspartame……? And if you take little responsibility for your physical health, what should the response of a ‘free’ health care service be that currently spends 1 in every 5 pounds mopping up the consequences of people’s poor lifestyle choices? And what about the leaders within our cities – what will they do to tackle the fast food/alcohol/sugar/tobacco industries and the supermarkets who cream profits from product placement and advertising of hugely unhealthy foods? I could go on……

 

And what about your mental health? The fact is: the UK has some of the unhappiest children in the developed world  http://www.bbc.co.uk/news/uk-14908194 (this is always true of places where the gap between the rich and poorest is wider and where materialism is prioritised over time). Anxiety and depression are on the increase and stress continues to be a major reason for consulting the GP. Some of this is systemic and it is a challenge to policy makers to think about the impact of their decisions on the mental health of the population. Austerity and deeper benefits cuts are having a profoundly negative impact on those already struggling. But there is also a challenge to individuals about what we allow our minds to be filled with. How much time in a day do you stop to be grateful, or to be still? How much of your mind space is taken up with addictive tendencies, be that to social media or pornography? How are you at forgiving others who have hurt you? If not very good – how much is the bitterness inside you having a good effect? If the bitterness is eating you up – what are you going to do – hold on to it? How much time do you give to things like singing and volunteering which are seriously good for your mental health?

 

To take Wilber further, we must ask how well we are socially. How connected are you to the people around you? According to the Office of National Statistics (ONS), the UK is in the bottom three nations in Europe for feeling attached to our local communities and for feeling like we can ask for help from people who love us in times of need – what is that about?! How much of our time these days is given over to screens and social media instead of actually having conversations that matter with people in the same street or even the same room as us? What is the social make up of our communities like? Can we see alternative economies springing up like time-banking? What is the provision like for children and old people? Who looks after your elderly neighbour when she’s just come out of hospital with a new hip? Could there be a meal rota on your street?

 

There is one other measure to look at – our systemic health. How much do we feel empowered within society to make a difference and effect change? If not much, then we generally don’t feel very healthy. For me, it’s one of the reasons why community involvement is important so that the unheard voices are given space to speak and to be listened to. How much do leaders within cities think about the impact of their decisions on the poor and marginalised? For some truly incredible work on this, check out the Leeds Poverty Truth Challenge (https://leedspovertytruth.wordpress.com/).

 

So, how healthy are you? You as a whole person and you in the corporate sense? Do you want to be well? If so, think more holistically – think about your physical, mental, social and systemic health.

 

My health check would ask these questions:

Are you eating and exercising well?

Are you drinking responsibly?

Are you taking time to be grateful?

Are you looking other human beings in the eye and building intimacy?

Are you connected to other people in your community?

Are you choosing to forgive others when they wrong you?

Are you taking care of others around you?

Are you walking in open spaces and enjoying this beautiful earth?

Are you singing on a regular basis and taking time to be creative?

 

The challenge to us all is to learn what it is to be really well. The challenge to the health service is to work far more integratively and take a much broader, wider, richer and deeper view of what it really means to be healthy.

 

 

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Reimagining Health


Knox Family-59
In this video blog, I tell the story of ‘The Fifth Monk’, taken from Tom Callanan’s blog (http://www.tomcallanan.com). It comes from the buddhist tradition and gives plenty of food for thought about the need for us to take the conversation about the future of healthcare ‘upstream’.

 

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