An Open Letter to NHS Staff – This ‘crisis’ is not your fault – you’re doing a great job!

If you work in the NHS, in any capacity, this letter is for you, no matter what your role.

 

Dear NHS Staff Member,

 

I write this to you as a GP, who cares for many people who work in the NHS and sees the huge stress many of us feel under. I write it as a ‘system leader’ in my role as Director of Population Health and as someone who has been a patient myself, twice in the last 12 months.

 

We are constantly told that the NHS is in crisis (I’ve even written blogs about it myself!), that we’re not meeting targets, that we’re getting things wrong, that we’re struggling to cope under the strain of demand but not being efficient enough and it can feel like what we’re doing isn’t up to the mark. With all the other current surrounding narratives we live with (like Brexit and Climate Change), things can so easily feel overwhelming.

 

So, I just wanted to write and tell you that the NHS is not in a crisis. We’re just underfunded and understaffed and we’re doing the best we can in those circumstances. Demand is growing year on year and we’re dealing with real complexity. We’ve been under the biggest and longest squeeze on our finances in NHS history, for the last 9 years, and the 3.4% uplift we’ve been promised, although welcome, is not enough to keep us running as we are and do the transformational work required of us. We don’t have enough people to deliver the work we’re being asked to do and so it’s no surprise that morale is low and burn-out levels are high. None of that is your fault. You are doing an amazing job. Every day, you turn up to work, in the context of everything else you have going on in your life and you are helping to deliver a truly world-class health service. Good job!

 

Amidst all the rhetoric you hear, the targets you feel under pressure to meet, the constant flow of people through the doors, the blame and complain (and sometimes bullying) culture that can grind you down, the traumas that you deal with every day, the pain that you help people process, the love and compassion that your pour out, the siloes and frustrations with the clumsiness of the system at times and the long hours – of which you work above and beyond most of the time…..know that you are more than your job and you are valuable just for who you are.

 

So, in all the busyness, remember to listen to and look after your own needs and those of your team around you. You can only do what you can do, and you’re doing a great job. Think about Maslow’s hierarchy of needs and how much you are attending to those things.

 

Physiological Needs – are you listening to your body? Are you getting time to have a drink, eat well, stretch, sleep and get to the toilet ok?

Safety – Are you feeling safe in your work? Do you feel protected? Are you worrying all the time about making mistakes? Do you feel it’s ok to make a mistake and be able to talk about it and learn from it, without fearing some awful consequences?

Love and Belonging – Do you feel like you are an important member of your team – that you matter, that you belong, that people around you care about you? Maybe in the humdrum and mayhem of everyday, we forget to tell each other.

Esteem – How is your self-esteem? Do you feel confident in who you are? Are you treated with respect and kindness and treating others with the same – no matter who they may be?

Cognition – Are you in a place where you can think clearly, make rational choices and in an environment which values learning and development?

Aesthetic Needs – Are you taking time to admire the beauty around you and enjoy life? Without this, it’s really hard to keep motivation alive, especially when things are tough and work feels really pressured. Taking time for this changes your perspective on everything else. How is your perspective? Is it in or out of kilter?

Self-Actualisation – Are you able to be spontaneous, making wise and creative, moral choices, problem solving without prejudice whilst accepting the facts in front of you?

Transcendence – This is the place we are aiming for as human beings – that ability to move out of our ego and into the place of gift from which we can love the ‘other’ and even our ‘enemy’ with the kind of transformative substance that changes the world.

 

The truth is, you can’t get to this place of self-actualisation and transcendence if the other areas aren’t looked after – so what needs attention? What are you noticing that needs taking care of? Don’t worry about all the pressures from on high – it’s all part of a system of biopower that needs to measure things to keep control. You – yes you, are valuable and important and the contribution you are making every day is phenomenal. You will certainly make some mistakes. It’s likely that you’ll feel overwhelmed at times, so listen to what your body, mind and heart needs and give yourself some space to attend to those things. Your own health and wellbeing really matters. So if you need help – and most of us do at different times, then please talk about it and give it some focus. We need to take care of each other – it’s ok not to be ok. Only when we create supportive environments for each other can we bring our ‘A game’ and keep providing the phenomenal care, innovation and transformation that we do every day.

 

Thank you a million times for everything you are doing, despite the struggles and pressure. Together, we need to create a culture of joy and kindness. That is partly the responsibility of leaders, but its incumbent on all of us, to treat ourselves and those around us with gentleness and respect. Go ahead and keep doing the great work you are doing every day – you really are a wonder!

 

Love and gratefulness

 

Andy

 

 

 

 

 

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Population Health and the NHS 10 Year Plan

https://www.kingsfund.org.uk/publications/nhs-10-year-plan

 

This is an excellent blog from Sir Chris Ham and Richard Murray at the Kingsfund and highlights some important issues that deserve real consideration and debate. Get a cup of tea, reflect on it and then join the discussion. Here are my reflections on it.

 

Improving population health and closing the health inequlaity gap are the two most important things for the NHS to focus on, if we are to have a heath and care service that works for everyone and is sustainable long into the future. It is not an easy nettle to grasp and is full of complexity, which is highlighted in this paper, but fundamentally, if we do not see a cultural shift, and ownership of these issues across the public sector, with population (and environmental) health written into every policy combined with a collaborative social movement for change, we will still be talking about this in another 15 years.

 

The reorganisations of the last few decades have been exhausting at so many levels and have not achieved what we have needed them to. It is indeed vital that we learn from these lessons and commit to at least a 10 year focus on improving population health, tackling health inequalities and integrating services, ensuring that we embed a culture of joy, kindness and excellence as we do so. We have reached a pivotal moment and we must break through our silos and see things tip towards a new commitment to improve the population’s health, together.

 

The funding question will not go away and it is really important that we are honest and open about what is actually going to be possible within the new funding agreement for the NHS and what will not be, especially if there is not a substantial investment into Social Care. Much of what we mean by prevention in Population Health relies heavily on other public sector partners, like Public Health, Education and the Police and the reality of their funding decline will make the transformation we need to see, especially in young people’s mental health very difficult, especially as the new deal for the NHS is not what it needs to be. For many Integrated Care Systems, the savings still required are so colossal that doing the simulataneous transformational work of population health and tackling the widening health inequality gap is a very hard task. It is a huge ask of finance directors to meet the constant demands of the regulators whilst also trying to be brave and shift resource towards more long term gains that do not meet the short termism of yearly budget requirements. The increase in demand due to more frailty and complex health issues, eye watering cuts to local government budgets (with profound knock-on effects to social care and public health), a target driven environment and low staff morale is making this all very difficult. It is not impossible but it is going to need realism and pragmatism about what can be achieved, by when. The choices being made about the funding of our public services are ideologically driven, and we need to ensure that feedback about the reality of austerity leads to necessary changes, so that we can have truly evidenced based policies.

 

Here in Morecambe Bay, we have recently launched the ‘Poverty Truth Commission’, one of several around the country. Many leaders from across our region sat with tears streaming down our faces as we heard story after story about the reality of poverty and destitution for people in our area. We heard from one young man, Daniel about how the closing of the youth centre on his estate and his local high school (both the only places where he knew he belonged and was safe), left him and many of his friends vulnerable to gangs. Moved, again and again through private rented housing, in order to provide for his siblings, he ended up selling drugs and guns, simply to put food on the table, ending up street homeless, with serious addiction problems himself. Many of us wondered how often we think about the short and long term consequences of the cuts being made and what kind of risk assessment is done in these situations. In her very powerful book, ‘Radical Help’, Hilary Cottam writes of need to put relationship back into the heart of our public service care provision, as we grapple with the joint issues of funding constraints and human need.

 

The points raised about improving productivity are important. Where we can be more efficient, we must continue to be so. Let’s pause to recognise, though, just how much has been achieved already. Culturally, we must learn to celebrate the positives and recognise the great work already being done in this area, which will inspire more of the same. The sharing of best practice and creating environments where we can learn from one another is absolutely key. This will most effectively happen through collaboration not competition. So, yes – integration must be a priority, but it comes with a health warning – if we don’t get culture right from the start, everything else will ultimately fail.

 

A Population Health approach is the only game in town. Wigan have achieved some really wonderful things, but there are some important things to understand about the context of Wigan that have made it more possible there. Firstly, there is clear political unity. The idea of population health is owned across all spheres and levels of government, and “safe seats” have led to a political continuity that has made long term planning far more successful. The ongoing politicisation of health and social care in other contexts makes this kind of transformation much more difficult. Secondly, there is a real humility in style of leadership that has been willing to a) openly share the complex issues and choices being faced, with the people of Wigan and b) deeply listen to the communities and therefore find a way through the problems together with a profound sense of joint ownership. It is this two-edged sword of necessary culture change and brave leadership with a social movement that makes it possible to cut into new ground together. We must be brave in talking to people in our local communities about the choices ahead of us and understand the importance of agreeing together who is going to take responsibility for the various pieces of th jigsaw which need to occur.

 

We know that 40% of our health depends on the every day choices we make as individuals, for example around what we eat or how much exercise we take. However, it is not as lovely and simple as this. There is far less choice available for our most deprived communities. Supermarkets do not stack the same amount of healthy food in their shops in our more deprived areas. Children have little choice over the adverse experiences they go through, how much sugar is in their breakfast cereal nor what is pushed at them through targeted advertising. The number of junk food outlets is far higher in areas of greater deprivation (see Greg Fell’s excellent analysis of Sheffield). So, when we talk about choice, especially in the context of poverty and education, we need to take a reality check and not simply point the finger of responsibility. This is where a people’s charter can be really powerful. Those in leadership play their part in taking care of the needs of the population and bringing in appropriate governance and a fair distribution of resource, whilst citizens commit to playing their part in staying healthy and well, and learning about conditions which they live with, so they can play an active role in being as well as possible, dependent on their circumstance.

 

Given the lessons from Wigan, or from global cities, like Manchester, and Amsterdam and what they are beginning to achieve around population health, there is a powerful argument, not only for combined health and social care budgets, but also for increased devolution of budgets. If we see what has been achieved in the Black Forest of Germany, with a very holistic transformation of services, including the connecting of communities through far improved transport links, we begin to reimagine what might be possible at a larger scale. Devolved budgets though must be a fair deal and not an opportunity for central government to make further cuts and then leave the blame in the locality. Devolution, if it is to work well, must come with new and fair legislation around taxation and proportionate allocation of resources.

 

All of this is only possible with the right workforce. I completely agree that we need both short-term and long-term strategies. I am not yet confident that enough work is being done at a predictive analytical level to really work out what kind of workforce we will require, if we shift to a fully integrated, population health model. This is the kind of workforce we must then build and it will by its very nature, be much more community and relationally focussed. This will allow us to build culture from the ground up and create the kind of working environments that are healthy and well, enjoyable to work in and therefore with a high retention level of staff. Perhaps our short term solutions need to be less reactionary and more proactive in building towards the future we need. Perhaps there are also more short term international opportunities and partnerships to be built whilst we plan for our reimagined future.

 

In making all of this happen, I think we need a little caution in too much over-comparrison with the American insurance-based systems. The ICS development we see there is based on a very different model and can look very appealing, because it overlooks too readily the 50million Americans who cannot afford a decent level of care. Yes, there are some impressive things to learn and some very data savvy things we can apply into our systems, but the fundamental differences between our ideologies and practices must cause us to pause and think about what is transferable and what we can do diffferently to ensure that everything we do works to close the health inequality gap, rather than widen it. This is where our greatest test will be. It is too easy when creating new agreements with the public to work with those who are already highly motivated to change. In so doing, we might actually make things worse, rather than better in terms of inequality. It is going to take determined effort and brave focus to ensure this doesn’t happen.

 

In short (!) I am very grateful for this paper and the issues it highlights. It deserves real contemplative reflection and a commitment by all to embrace this future together. We cannot achieve population health and the tackling of health inequalities alone, but together, we can.

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Four Circles of Population Health

Tweet In my previous blog in this series, I wrote about the ‘Pentagon Model’ which we have developed in Morecambe Bay to help us think about how we manage Population Health. The Pentagon approach actually forms one of four parts of some over-lapping circles, based on 4-Ps (Population Health Approach, Partnerships, Places, People Movement), which [Continue Reading …]

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Creating a Culture of Excellence

Tweet 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 [Continue Reading …]

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Creating a Culture of Kindness – Vlog

Tweet 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!     Share This:

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Creating a Culture of Joy – Vlog

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Lessons From Helsinkii

Tweet 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, [Continue Reading …]

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Creating a Great Culture – Part 1

Tweet I’ve recently finished reading the extraordinary book, “Legacy”, by James Kerr. It is a book about the culture of The All Blacks, the most “successful” sports team in the world. If you are involved in leadership, at any level, especially if you are passionate about developing the culture of your team, I would heartily [Continue Reading …]

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Building Healthy Towns and Regions

Tweet The other week, I was phoned by a BBC producer to ask if I would take part in a discussion on the Victoria Derbyshire show about how we can build healthy towns. It’s partly due to the work we’re doing here in Morecambe Bay with our communities around being more healthy and well, especially [Continue Reading …]

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Creating a Culture of Joy in the NHS

Tweet 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 [Continue Reading …]

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