We’re Not Ready for Winter – We Need to Be!

The winter hasn’t even hit us yet. But it will and it’s going to hit us hard. Harder than we know. Harder than we are prepared for. Do you remember January 2015, with queues of people lying in corridors in our Emergency Departments, and a high spike in winter deaths? One of the people I respect most in the world of Public Health, Prof Dominic Harrison, highlighted to me this week, that it was a three-fold, intertwining cord which led to the devastating outcomes: an ineffectual flu vaccine, high staff vacancies in the NHS, and high staff sickness rates. But here’s the thing – this year we have more factors (Covid-19, incoming Influenza, staff gaps in the NHS, people having to self-isolate and sickness levels rising – this week our surgery had 14 staff off with C-19) and although, so far we haven’t seen the spike in deaths associated with the rising number of Covid-19 cases (thanks to better treatments), our hospitals are filling up fast, whilst the mantra remains, that the NHS must get back to pre-Covid levels of operation. This is going to be a tough winter. And it’s going to be worse, as it always is in our most deprived communities, which will further widen the health inequalities gap. And people are going to die, not only of Covid and influenza, but of other preventable things like heart attacks, strokes and suicide, in higher numbers than usual. What am I, a prophet of doom? Well…..I hope not! But this is a wake-up call.

 

It’s no surprise that so many people feel a smouldering sense of anger towards the government. There is no doubt that things could and should have been handled differently from the beginning. It’s no use saying – well….we didn’t know what we were facing, we weren’t prepared for this….. the government didn’t even follow their own advice from their preparedness exercise three years ago, they have outsourced test and trace to companies with no track record or expertise in the world of public health to the tune of £12billion and it doesn’t even work effectively. They have given contradictory advice to different regions of the UK, they have continued to allow foreign travel, they have failed to adequately explain the reasons for certain policies which key members of their inner circle haven’t even followed, they have briefed key city leadership teams through the press and failed to win the public’s trust – something which is so crucial at such a time as this. They have “followed the science” and then not followed the science…..it has been a shambles and it’s no wonder that people are disengaged.

 

HOWEVER – this is not the time to let our cynicism get the better of us! What we have to face is that we are where we are and we’re heading into winter, and our anger towards these various failings is in danger of causing us to embrace apathy or rebellion – both of which will have terrible consequences. So right now, we need to keep our heads and we need to take a deep breath. There will come a time for the government to answer serious questions about how they have handled this pandemic and the decisions they have made. But it is not now. Now, we need to look ahead and be really pragmatic about what we’re about to face together.

 

Firstly, I would implore the government to listen to the wisdom of Prof Devi Sridhar. As the youngest ever Rhodes Scholar and fiercely respected Professor of Global Public Health, she is worth listening to. She has not been shy in her critique of where the government have made mistakes. But she is also speaking with a real sense of pragmatism and kindness, as she draws on lessons from across the globe to develop a roadmap for the way ahead. Her advice to government is as follows:

  • Ensure the Test, Trace and Isolate system is robust. Test results need to be back within 24 hours, 80% of contacts must be traced and strict adherence to the 14 days isolation is vital. The current system still isn’t working effectively enough, despite an eye watering bill with no sense of accountability or responsibility for it’s failure. It is not too late to ensure that local directors of Public Health can lead this work heading into winter and ensure that all available labs are put to effective use.
  • Solid, consistent and clear public health messaging needs to go to the public through every means possible. There needs to be rationale and helpful explanations about why certain measures are being chosen.
  • We need strict border measures to stop the virus from re-circling.

Secondly, as the public we need to take whatever responsibility we can to ensure we continue to do all we can. Conspiracy theories are not even vaguely helpful right now. And although it’s true that death rates have been lower than expected, there are other things to consider. This is still a dangerous virus – it will lead to many extra admissions to hospital through the winter period, especially linked with Respiratory Illness and it will affect unsuspecting and previously healthy people with the effects of long-covid – I have seen the effects of this in my (young and previously fit) patients and friends and it is truly debilitating. With all the other things we have to cope with this winter, we can’t afford to let our guard down – not now. We know from public health data that the vast majority of spread is between family, friends and neighbours. We also know that it won’t just be Covid-19 that kills people this winter. Higher than normal deaths from other illnesses/conditions are expected across the board. So, here are some sensible things we can all do to try and stay well:

  • Have a flu jab if you’re in one of the ‘at risk’ groups
  • Take worrying symptoms seriously! Don’t ignore chest pain (especially if it’s worse when you exert yourself), or new lumps and bumps – especially in your more private parts, or bleeding from somewhere you don’t normally bleed from, or unexplained weight loss. See your GP!
  • Wash your hands regularly
  • Wear a face mask when out and about
  • Spray and wipe down surfaces
  • When you cough or sneeze, do so into your elbow crease
  • Keep 2 metres apart from people who are not in your household, and wear a facemask if you have to get closer
  • Keep within your household bubble – the vast majority of spread is now happening between family, friends and neighbours – we can’t be blazé about this!
  • As far as possible (recognising that choices are significantly reduced for many of our communities), make good choices for your own physical and mental health:
    • Eat well – be determined to fuel your body with good nutrients – if you’re trying to get to a more healthy weight then significantly reduce salt, alcohol, sugar and carbohydrate in your diet. Consider taking a vitamin D supplement through the winter – 1000units daily – only about £1 for 60 tablets from most pharmacies.
    • Exercise – this doesn’t have to be anything unrealistic or intense – stop looking at other people’s sculptured bodies and feeling crap about yourself. You are beautiful! Just take a walk, if you’re able, every day – whatever the weather, and get some fresh air. If you’re unable to walk, try some gentle chair-based exercises – it doesn’t have to be anything heroic – something is better than nothing. Do more if you want, but let it become enjoyable, rather than a chore – something you’re choosing in order to make life better and more happy.
    • Be grateful – everyday, when you wake up and before you sleep – try and think of three things you can be grateful for that day.
    • Breathe deeply and use breathing techniques to calm yourself down, like box breathing (breathe in for 4, hold in for 4, breathe out for 4, hold out for 4).
    • Connect with people – even if it’s via zoom, facetime or the phone – whatever it takes – connect with other human beings around you. Social isolation is literally a killer. We must take care of each other. Ask people how they are and genuinely care enough to listen. Some people are going to tell you they aren’t sure they want to carry on living. Ask them if they are thinking about ending their life. If they say yes – ask them if they have made any plans. Either way, take this seriously. Help them get help. Ask them if they have phoned their GP yet. Tell them you’re going to to keep walking with them through this tunnel. Reassure them that there is a light even though they can’t see it right now.
    • Learn something new – a language, a skill, whatever you fancy – give it a go.
    • Relax – seriously switch off the 24 hours news cycle, disconnect from too much social media and take time to do things which are good for your soul – sing, dance, read, play games, take long baths, whatever helps…..
    • Sleep – our bodies and our minds regenerate when we sleep. Sleep is good!
    • Above all – keep love and hope alive. We’ve got to dig deep to keep loving each other – being kind in our attitudes, even towards our enemies. And keep on keeping on hoping. If you’re not sure how, this podcast with Brené Brown and Michael Curry will help!

 

Thirdly, the NHS is not yet ready. Yes – there have been some remarkable things which the NHS has done to respond to the first wave of Covid. Contrary to some misleading articles about General Practice, we are and have always remained open and available to our patients. We are triaging all patients via the phone to work out how we can best help and employing loads more technology to help us do this. It’s so much better for a young mum of three kids to be able to have quick video-call about one of her children’s rashes than have to lug them all down to the surgery. It’s great that we can now supplement a phone/video call with an advice sheet sent to your phone. It also means that we can prioritise who really needs seeing face to face and keep our premises as Covid-secure as possible. Many community staff were redeployed from their usual work, such as Speech and Language Therapists, Occupational Therapists and Physiotherapists, into the Nightingale and Rehabilitation hospitals, meaning they were taken away from their usual work, with a huge amount to now catch up on. This was not without cost to families who needed their support or were awaiting a diagnosis, and added to the strain in General Practice also. It was tough. But it was worth it. And we’re so grateful for the way the public were overwhelmingly understanding towards us as we tried to flex our services to cope with the demand.

 

However, we need to take a radical stocktake of where we are and again put into motion some very different ways of operating over the next 2-4 weeks. It will allow us to work in a way that is safest for the public and will provide a sense of reassurance. Although I welcome the reopening of the Northern Nightingale Hospitals – as usual, the focus is far too much on the Acute Hospital sector and not enough on how we can help people stay more well in the community and prevent admission, particularly in our economically poorest communities. It’s important that the public understand that we need to reorganise our services in the community again in order to try and enable as many people as possible to stay well through this winter, particularly in our poorest communities, where admission to hospital and early death rates are always significantly higher.

 

I have nothing but compassion and camaraderie with GP colleagues as they cope with a huge surge in demand, (just indeed as I do with all NHS workers and carers right now, whatever their role). What I believe we need to do NOW though is change the way we’re working so that we can give real focus into the areas which are likely to affect people’s health most significantly over the months ahead, support our community colleagues to focus on various aspects of their work more effectively and enable our teams to be resilient and stay well themselves through the winter, whilst serving the communities with their usual brilliance. Here are my suggestions, which we are exploring in more depth across Morecambe Bay and indeed our Integrated Care System across Lancashire and South Cumbria (though important to note that this is more about function than form, so might ‘look’ different in each locality):

 

  • accept now that we cannot get back up to pre-covid levels of activity, for example in routinely scheduled operations, and if we try to, it will lead to more unnecessary deaths. This is a big ask for people who are waiting for their hip to be replaced, or their hernia to be repaired, but we have to be realistic about what is possible with the resources we have available.
  • re-focus and align existing capacity in order to ensure a more coordinated approach to addressing demand.
  • target additional resource to mobilise capacity where it will have the most impact.
  • use data and evidence of risk and vulnerability from COVID-19 in a more systematic way to inform a response that is scaled appropriately.
  • In order for this to work practically, we must create a model which makes this possible. Perhaps one way is by reorganising into a model of Red, Amber and Green Community Hubs, supported by a co-ordination centre, which pulls together the data and brings aid when practices are struggling, could work in the following way and allow us to work as effectively as possible (recognising that this may vary according to Primary Care Network/ICP/MCP need and capability/capacity):

Red Hubs (which can be remote in terms of triage) staffed by Paramedics, GPs and Nurse Practitioners, to deal with COVID-19, Flu, and Acute Respiratory Illness (i.e. anyone with a fever, cough or breathlessness). It may be that out of hours providers may already be in place to supplement and support this model.

Amber Hubs – a remodelled care co-ordination team approach led by the General Practice Team with proactive support from community (including mental health) teams.  They would use an asset based community development model of Population Health Management and work WITH communities to:

  • Focus and drive on proactive long-term condition management AND other acute illnesses that don’t fit the criteria for the red hubs.
  • Have a driving focus on proactive long-term condition management with particular emphasis on conditions more vulnerable to poor outcomes from COVID-19.
  • Be supported by redeployed medical specialities.
  • Fund and support the Community Voluntary Faith Sector to partner with Primary Care and Community Teams to create a really resilient partnership in doing this work together, recognising the HUGE impact the 3rd sector makes to this work and how fragile they are in terms of adequate resources.
  • Be sited so as to ensure accessibility to residents within the 20% most deprived communities within each ICP/MCP.
  • Have attached to them place based multidisciplinary assertive and active case management and care co-ordination teams (think spokes) as outlined previously. These teams would have a focus on the “priority wards” and groups experiencing higher levels of social isolation.
  • Take a “more than medicine” approach by having active in reach from other partners reflecting broader, social needs that are barriers to improved health and wellbeing; social prescribing, housing, employment and more as informed by the data.
  • Cardiovascular Interventions
    • Hypertension – we have too many patients with a BP >150/90 (current guidance shows we should be aiming for <135/85 for the general population and <130/80 for those Diabetes or known heart disease). We will best prevent MIs and CVAs by being much more proactive in this area.
    • Atrial Fibrillation – ongoing protection work by ensuring appropriate anticoagulation in those with a Cha2ds2vasc score of over 2.
  • Diabetes (and Cancer)
    • focus on healthy weight, driving down BMI where possible, through targeted interventions and
    • reducing HbA1c in people through targeted lifestyle interventions and medication where necessary.
  • Respiratory Disease (and Cancer)
    • Stop Smoking interventions
    • Weight loss programmes
    • Winter warmth schemes in homes and damp removal – this will be vital in keeping admissions down
  • Cancer – Getting a real focus on 2 week wait referrals with appropriate messaging to the public
  • Mental Health – Suicide Preventions
  • Mental Health reviews
  • Targeted messaging to the public to help them understand why and how things are changing
  • Suicide awareness training
  • Frailty and Care Home work – ongoing support and focus on the frail and those in care homes

 

Green Hubs – these will focus on:

  • Musculoskeletal problems – physio first and possible redeployment of Orthopaedic Surgeons and Pain Specialists, to run clinics and provide joint injections in the community rather than surgical procedures, to see people through the winter period
  • Other day to day, essential General Practice issues – baby checks, smear tests, dermatology, rheumatology, ENT, low level mental health etc – run by a reworked and repositioned team

 

 

The model above won’t work for all, but the principles are important. It might all seem a bit radical and it’s true that there would need to be a significant amount of resource and support flowing into the community to enable this – however, if we don’t do something like this, then it’s like knowing an earthquake is coming and not bothering to take aversive action. We don’t have the personnel we need right now, but partnering with the voluntary sector (with appropriate resource allocated) and ensuring we have the right data help and support will make this more possible. Finances must be freed up to support this model and NHSE need to give the ICS teams across the nation some slack to take this more proactive approach. It will actually lead to huge savings (of lives and money).

 

We’ve already lost a lot of people to Covid-19. We’re heading into a serious economic catastrophe and a winter of discontent. Good public health and good health care IS good economics. If the government heed the warnings, if the public take this seriously and work with us, if the NHS can reorganise, even at this late stage, then we will significantly improve our chances of getting through this winter well together. We won’t have another opportunity to ‘get this right’. I hope we will act now and find that we really can make it through together.

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Good Grief

The world has changed. We cannot go back to where we were, nor continue to head in the same direction we were set upon before this crisis. But that is easier said than done and will be impossible if we do not embrace the grief of what we are journeying through together. There has been and continues to be painful loss. We have lost dear friends, family members, neighbours and colleagues. We have lost jobs, income, holidays and social gatherings. We have missed births and birthdays, key social events, final goodbyes and funerals. We are bereaved of whole ways of behaving – our ways of life, everything we’ve known has been entirely interrupted.

 

For me, as a type 7 on the Enneagram, it’s all too easy to engage in the future, to think about the ‘what next?’, to avoid the pain of the here and now, by letting my imagination run wild of what the world might be like instead. But we cannot and must not miss the vital part of our current journey, which is to recognise, embrace and partake in the grieving process. Grief is not comfortable, it is not easy, it is not enjoyable – in fact it is both tumultuous and painful…..but it is good. Refusing to enter into it, or trying to suppress it, will only lead to a deepening of the trauma and a delay of this inevitable experience.

 

The thing about grief is that it is unpredictable and what makes it even more so in this current experience is that it is both personal and corporate. However, the cycle of grief is well known and although each of us will go through the cycle differently, it’s worth recognising where in the cycle we might be, both as individuals and as a wider community/society.


This is the classic ‘grief cycle’ (I’ve borrowed the graphic from psychcentral.com) and it demonstrates well how the experience of grief is neither straightforward nor easy. However, psychologists agree that each of us will pass through each of these phases, no matter how briefly – though we can remain stuck in some areas for quite some time.

 

The isolation of this time has been the starting place for most of us. For some that was coupled with an acceptance that we are where we are, but for others there was a denial that this could be real and a refusal to engage with the idea of social distancing (although with police enforcement, this quickly began to change!).

 

The anger phase is clearly present for many at the moment, and understandably so. Anger is not wrong, it’s how we respond to it that becomes the issue. Sadly, in many households we’re seeing a rise in Domestic Violence , particularly towards women and children and this is something we need to take really seriously. Learning to control our anger and find a positive outlet for it is absolutely key. There are all kinds of online resources to help with this, but the deep cuts to social services and policing over recent years have made it difficult to work with families in a more proactive way. The Violence Reduction Unit in Lancashire, led by Detective Chief Superintendent Sue Clarke, who is a brilliant leader,  have done some incredible work in this area over the past couple of years, which is well worth learning from. The approach is much more productive than traditional methods of dealing with this issue and involves being with families more proactively to bring restoration and redemption into broken situations.

 

We’re also seeing the rise of a corporate anger. Tony Blair stated the other day that this is the most difficult time to contemplate being in government, and it’s true that we are in unprecedented times, but he feels our response nationally was slow. However, many feel that more serious questions, now being asked across the media spectrum, still need an answer:

 

These are all important questions that require an answer. Anger can be used to facilitate the right kind of conversations to bring challenge to the status quo and demand that it never leads us here again. The outcomes we are seeing were not inevitable – so what will we learn? What will be different? How will we change? If people in positions of power are willing to own up to mistakes, are we willing to forgive? I hope so…..how do we rebuild society otherwise? We must be able to learn and change our ways. It’s at the heart of what it means to love. But we must also recognise that some of this anger is simply part of the grief cycle and there may be no answers. We’re angry in part, because we are grieving. Sometimes our anger brings challenge and change, but sometimes we yell into the night and are met with silence.

 

Depression in grief can become clinical depression, but the word, in the context of grief, more describes a sense of deep sadness, loss, numbness, apathy and is often accompanied by tears. We must not try and keep a stiff upper lip, or push this away. Some of us will feel this more acutely than others, depending on our personality type, but this is a vitally important part of the process. This deep sadness can catch us unawares. It can come almost out of nowhere and we can find ourselves having a good cry in the bath or struggling to find the motivation to get out of bed of a morning. Talking about these feelings is absolutely vital, and it’s important that those of us who listen, ensure that the person experiencing these emotions feels heard. They don’t need fixing. They need validating. They need to know it’s OK to feel like this. We can’t just wish it away or get back on with things. There is a certain wallowing in this place that is extremely healthy and right. It’s true, we don’t want to get stuck here, and by putting some positive measures in place, like exercising, eating well, mindfulness and keeping a positive sense of routine, we can avoid becoming more mentally unwell. However, we must not try and rush through this phase or refuse to embrace the pain of it.  But this can become a very dark experience and some people will wonder if life is even worth living. We can find ourselves asking searching questions: Can we really go on without our loved one? Will we ever get through the brokenness of this current situation, when we have lost so much? If this becomes overwhelming or there are serious thoughts of not wanting to carry on with life, this is where therapeutic interventions or medical treatment in the form of medication can be really important and literally life-saving.

 

At a corporate level, we share a sadness that 20000 people in the UK and 200000 people globally have lost their lives so far, due to COVID-19 – and that is just the recorded deaths. We will potentially feel lost that a whole way of being together is no longer possible, nor perhaps, desired. The artists will help us the most here. Songwriters, painters, choreographers and playwrights. Are we mature enough to embrace the songs and dances of lament? DO we know how to do this?

 

Bargaining is about us trying to begin to formulate some meaning or sense of what has happened/is happening. We might find that we want to talk about our experiences more, tell our stories, reach out to others and explore some of the ‘why’ questions we’re wrestling with. We might find we start ‘big conversations’ with God or ‘the universe’ – some thing like – ‘if you help me get my job back, then I’ll live a good life from now on’ or we might find we’re dealing with several regrets in our interactions or relationship with the person we have lost.

 

Acceptance is about realising that we are where we are and we cannot change a thing. It allows us to breathe deeply into the reality of the horrors we have walked through and begin to face into the future. Some people think of the grief cycle as more like a river with the grief cycle being a whirlpool that we get stuck in for a while. We go round and round, but eventually we come out the other side. On a personal level, perhaps, before we entered the whirlpool, we had a dearly loved one in our boat with us and we entered this whirlpool once that person became sick or was no longer in the boat with us, because they had died. The whirlpool can feel overwhelmingly difficult, with the stages above. We come out of the whirlpool with an acceptance that this dearly loved person is no longer in the boat with us….but there are other boats that we travel alongside, and perhaps there are others who still remain in our boat. We must now learn to live in this boat, without the person who was with us before but knowing we can face the future with our other companions. At a corporate level, this is about us sense making that the future cannot be like the past. Things have fundamentally changed. We cannot go back to how things were and so together we can build an altogether fairer and kinder future for our global population and the planet we inhabit together. This becomes what some refer to as the 6th stage of grief – ‘Meaning’. We begin to make sense of what we have journeyed through and use it to transform our experience of the world and how we want to live in it. My next blog will explore some of the meaning we may find the other side of COVID-19.

 

Whatever your experience of grief at this time, embrace it and talk about it, but don’t try and hurry it away. Good grief is a part of life and enables to process our loss, feel our pain, heal our wounds, accept our scars and find a new future. The ‘Good Grief’ movement is something I would really recommend exploring, especially if you are struggling to process your own grief. There is also lots of mental health support available through your local GP or online via nhs.uk. Grieving allows us not only to engage with the pain we are going through, but allows us to let go, so that we can reset and rediscover a way forward together. It’s impossible to walk through it alone, which is why as the city of Liverpool reminds us in the amazing song, sung at Anfield, friendship is everything.

 

 

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A Difficult Conversation About COVID-19 – Care Planning

Tweet For those of us more at risk from Corona Virus, over the next few days and weeks, your GP will be in touch to have a difficult conversation with you about care planning. That means a conversation about what your wishes would be, if you become very unwell from COVID-19. We find ourselves in [Continue Reading …]

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Facing Death

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

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Time to Face the Music

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Death – Allowing it to Happen Naturally

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Death – A Difficult Conversation

Tweet I hope that our towns and cities can become compassionate communities in which people live and die well. We need to break through our fears, especially in the UK in talking more openly about death. Share This:

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Compassionate Communities

Tweet I hope that Lancaster, the city in which I live may become the first official compassionate city in the UK. I don’t mind if it isn’t, but I do hope that many cities choose to take on this mantle. Here is a beautiful and moving animation of what becoming a compassionate community is about. [Continue Reading …]

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