Why Are We So Inactive in the North West?

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

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

The Morecambe Bay Mile A Day!

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

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

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

Our Nation’s Biggest Public Health Problem

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

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

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

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

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

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

The Extraordinary (Healing) Power of Forgiveness

There are many times when people come to see me, as a GP, and I cannot find a physical cause for their pain. There are various other conditions when people have what we call “medically unexplained symptoms”. For others, they can get stuck in a rut with their mental health and feel unable to get out of it. In the west, we are not as comfortable as we might be in dealing with the concept of spiritual health. Our spirit, the true essence of who we are, can also suffer damage and ill health, which in turn can lead to physical and psychological manifestations of that same pain. One of the things I have seen time and again as one contributing factor is when someone is finding it difficult to forgive a past hurt. In this vlog I talk about the great power of forgiveness in helping us to be more well. In the one after this, I will talk about how we can actually go about forgiving someone who has hurt us.

A Healthier Story

So, we start 2017 with General Practice “skating on thin ice”, the NHS as a whole “creaking on the edge” and major concerns over funding and waiting times. Why don’t we step outside of that rather repetitive and boring story, and find a new one together – one that resonates far more with the ancient paths we once knew?

The world is changing, and not in a good way. We are becoming more separated from each other, our organisations and systems dehumanise us and we are becoming less well. The story that the ‘benevolent hand’ of the free market will work everything together for good is exposed in it’s nakedness, like the Emperor’s new clothes. The fabric of our society is unwinding as we become more disconnected from our own sense of wellbeing, our communities and the land on which we live.

How do we recover a sense of wellbeing? Where will we find healing for our past, present and future? How can we expand our own vision of what it means to be well, focusing not only on our physical health, but also on our mental, spiritual, social and systemic health?

How might the General Practice community move from being a group of health heroes, who fix people when they are unwell, to letting go of that old and unsustainable paradigm, learning instead to co-host, with others, an environment in which a community can be healthy and well? It doesn’t mean doing away with skills that have been crafted, but using them to empower others to be partakers and not only recipients. What if GPs or ICCs (Integrated Care Communities) faced up to the fact that they don’t have all the answers, nor the resources, nor the power to fix the problems in their local populations? What if they allowed themselves to become more of a part of their community, rather than separate or slightly aloof from it? What might a co-operative model look like? If every patient owned a small share of the practice and it truly ‘belonged’ to the community, just how radically might things change, without the need for huge ‘take overs’ by local hospital trusts or private healthcare firms? If we are to find a new way forward, we must all be willing to let go of what we have known and the power which we hold. We have to let go of our need to chase the money and imagine that we are like the city of Detroit, declare ourselves bankrupt, financially and spiritually and then together, break down the walls that keep us separate and find our way together.

When we host spaces in which communities can come together, rather than trying to be the experts who know how to fix everything, we let go of our need to be the heroes and come into a space for shared learning. As I spend time with a community of people recovering from various addictions in Morecambe, I find I don’t have the tools to fix things. However, I do find, that together there is a huge heart for a better and more healed society for everyone, so that others do not need to find themselves in the grip of addiction. We need to know less and find more corporate wisdom. We need to share our gifts and find the beauty of reciprocity – that it is in the giving and receiving of one another that we find a way forward in positive peace.

The future of our health and wellbeing relies far more on our interconnectedness and our community than on the systems we have built. Our systems must give way to become subservient to the longing of our hearts rather than the task masters which drive how we organise ourselves and live out our lives. Co-operative community gives us an opportunity to live something much more radically loving and kind, in which people and the planet really matter. Today is epiphany! A day in which some people with real wisdom realized that God came as a baby, weak, helpless and in need of community for health, wellbeing and development. If God is and needs community, how on earth have we become so disconnected from that story and made our whole way of being about experts and empires? Here is an epiphany for 2017. If God did not come as an imperial expert, but in weakness and humility, we need to do the same, if we are to find any hope for the future. The system will not change from the top down, it’s too invested in the broken story to be able to do so. But we, the people, can together be cogs that turn in new ways and realign ourselves with a way of being that brings better and more holistic health for everybody, everywhere.

Here is another interesting blog, from a slightly different perspective about how community really is the future of medicine – well worth a read, when you can make space for a nice cuppa and some left over Christmas cake (good for your wellbeing)!

The Future of Medicine is Community

Personality Health

imgres We often talk about physical, mental, social and even systemic health, but we don’t often think or talk about the health of our personalities. Our personalities are shaped by our self-esteem, our values, our truths, our needs, our struggles, our instincts and our gifts. They impact every part of our lives, relationships and interactions with the world at large and although we give some focus to understanding them through tools like Myers-Briggs, the Enneagram and Strengths-Finder, (perhaps to make us more successful), we give little thought to how healthy we are when it comes to this subject.

enneagramdisorders Now, what is particularly interesting to me as a doctor are 2 things related to this. Firstly, our personality type is hugely linked to the kind of mental health problems we might be more likely to develop. I wonder how often clinicians see the presentation of a mental illness and are able to talk with the person in front of them about which aspects of their personality might need therapy in order to help their mental health improve? As the whole area of positive psychology develops, it is vital that there are learning environments in which clinical teams can learn about innovative approaches in psychology that avoid the over prescribing of medication, especially in our younger population.

The second area of interest is to do with how we can be more self-aware of how healthy we are or when we have reached a point at which we can no longer really help ourselves but need others who love us or care about to to intervene. Below is a chart (of sorts) which I learned about during a weekend on the Enneagram. It helps to explain aspects of personality health. I recognise that at times I am functioning more healthily than at other times, due to a combination of internal and external factors. I think there are behaviours we can be aware of, or ways in which we are operating in relationships and situations which should serve as a WAKE UP CALL to us. When we notice more negative patterns, we need to take stock of where we are and work out our lines of responsibility to help us back into a more healthy state. However, if we don’t, things can continue to worsen until we reach a point at which we need others to intervene on our behalf and rescue us from our self-destructive and damaging sickness.

We can make a comparison with heart disease. For much of the time, our hearts function healthily. However, through a mixture of internal and external factors, our hearts can become less healthy. When this occurs, our body will fire some warning shots to us, giving us a chance to change before something more serious occurs. This might be signs and symptoms do do with our weight, nutrition, fitness, level of breathlessness, vague chest pains, markers in our blood tests – like high cholesterol and high sugar, rising blood pressure etc. However, if we ignore the opportunities to change and continue with our unhealthy choices, eventually we will reach the point at which we have a significant event, e.g.the start of angina, a heart attack, a stroke, the development of diabetes. At that point we need the help of someone else – we can no longer do it on our own. Of course, we still have choices and can reject the help on offer, but if we do, we risk our own demise and ultimate death.

My point is this. If we do not take the health of our own personalities seriously, there are serious and significant consequences, not only to ourselves but those around us and the world we live in. Many of us reach a point when we need help, but might not even face up to this, due to the poor health we are in. In those times, we need those who love and trust to be brave enough to reach in and offer us a life line. We may have even reached the place where we need resuscitation, when all our pride has gone. When we have ignored the red flag, we need those around us who will risk our total rejection of them to love us enough to offer us a way back to health. We need to take the health of our personalities seriously – it actually has a huge bearing on all the other aspects of our health. We also need

enneagram-health

HEALTHY

1. Level of Liberation – Ego transcended – balance/freedom – i.e you become a gift
2. Level of Psychological Capacity – Ego as particular mode of being – choice of how to be
3. Level of Social Gift – Ego operating in constructive way – sublimating ego

Wake up Call – need to listen to internal warning bells

AVERAGE

4. Level of fixation – Ego role assumed – falling asleep (not self-aware) – losing contact with presence
5. Level of interpersonal conflict – Ego controlling environment to support self – manipulative/defended
6. Level of overcompensation – Ego inflation, demanding others and reality support it – aggressive defence

Red Flag – need of help from others

UNHEALTHY

7. Level of violation – Ego willing to violate self and others to maintain itself – abusive/desperate
8. Level of Delusion and compulsion – Ego loses touch with reality – out of control – personality disorder
9. Level of pathological destructiveness – Extreme pathology and/or death

Solutions Focused Thinking in Population Health

My last blog focused on how we can think about solutions instead of problems in the NHS. Well the same is true in thinking about the health of our whole population. Yes there are some problems! We have growing health concerns with obesity and diabetes. We have huge health inequalities. There are major issues with housing, economic policies that are not working for huge swathes of our population, with more people having to use food banks, struggling with fuel poverty, living in damp houses and unable to make ends meet. Yes, our kids are spending more time on screens and less time in activity. Yes, the sugar lobby, alcohol lobby and advertising giants have far too much power. Supermarkets are designed deliberately so that we buy things that are bad for us. And sometimes, we just make poor choices (if you can call them choices, which for some people, they aren’t always) – we do not all live as healthily as we could – we eat the wrong stuff, work highly stressful jobs, and exercise less than we are recommended to. Mental health issues are on the rise, especially for teenagers, due to crazy targets and league tables, with all the pressures they face. We are less happy and more separated than we ever used to be, despite the rise in social media…..(or maybe because of it……)…..Man, I can paint a negative picture – it’s like storm clouds and darkness everywhere……..

But what if it wasn’t that way? What if we got a bit angry about it, but instead of finding someone to blame and pointing the finger; instead of getting all tribal and throwing stones at others, we chose to use our energies creatively to find solutions, to work together and make positive changes?! Let’s put away our pointing fingers and our ranting tongues and let’s work together for a better future for everyone! Doesn’t that sound good?! It’s what we’re trying here in Morecambe Bay, and I’m hoping it spreads like wild fire so that we can become a place where health abounds and beauty surrounds (that’s the motto of this place!). That doesn’t mean we stop speaking truth to power, but we also let our actions (and maybe our votes) speak louder than ever before.

We’re talking together, taking time to dream about what it would be like if we were the healthiest area in the UK. We’re training up many people to host conversations, so that we break down walls and learn to collaborate for the sake of everyone. We’re not just dreaming about physical health, but mental, social and systemic health as well. We’re encouraging those who want to rise up and take some leadership, to be pioneers in the stuff they are passionate about. Even in my little town, we now have a mental health cafe that is literally saving people’s lives, because a lady called Jane wanted to make a difference. We have a cafe for all the people who have circulation problems because one of our nurses wanted to break people’s isolation and improve their healing rates at the same time. We’ve got a carers cafe, a dementia cafe and will soon have a breathing cafe for those who have severe COPD, sharing ideas and diminishing anxiety. We’ve got exercise classes to help with pain, a community choir, dog poo wardens to help us take more pride when we walk down the street and food banks to help those who can no longer afford to eat.

We have 2000 kids aged 4-11 running a mile a day at school with staggering results for our children here in terms of physical, mental and educational health. We’re hoping over time, this becomes the Morecambe Bay Mile, part of a cultural shift towards being more active. We are working with local chefs and supermarkets to enable people with pre-diabetes or weight struggles to eat more healthily. We’re choosing to lead by example in the NHS to work well and flourish in our work places. We’ve made a commitment to see the 5 ways to wellbeing in every NHS organisation and we’re hoping many other systems and businesses will follow us in this. We’re finding radical ways to help people who are struggling with alcohol and drug addiction, get free and stay free with amazing results. We’re helping people live well with and beyond cancer. We’re changing the way consultations happen in the NHS to enable people to make more informed and better choices about their own health and conditions, so they feel empowered to make changes that work for them rather than beaten up when they go for an appointment! We’re launching the Morecambe Bay Poverty Truth challenge, learning from those who are lived experts in poverty to help us work together and care better for those most struggling in our society. We’re having difficult conversations about death to help people be prepared for every eventuality.

All of this has started in the last year! What else might be possible? What other dreams will be awakened? What other partnerships, collaborations and relationships might be formed? Being all tribal and accusatory of others saps our energy and stops us being creative. Mud slinging and blame will achieve little. We have to work from where we are. We have to build bridges and work together. We have to build a future of positive peace and that means binary thinking is over! The future doesn’t have to be full of doom and gloom. It is alive with hope! What resources might we find? What talents might we discover? What might we see develop over the next 12 months/years/decades as we look for solutions together for a better future for everybody? Don’t you feel just a little bit excited?

Here we go round the NHS Mulberry Bush!

One of my favourite songs as a 5 year old was ‘Here We Go Round the Mulberry Bush’. I’ve been involved with the NHS for 17 years now and every winter, we do this same dance around Emergency Departments and the total mess that surrounds hospital admissions, discharges and an ever growing list of missed targets. Unfortunately, it no longer applies only to winter. It really is an absolute shambles and the problems are only too obvious. In this blog, I plan to outline them, but hopefully move away from the classic “who’s to blame” arguments and push through towards thinking about solutions…..none of which are easy, but neither are they rocket science!

So, here is a list of problems:

We have an increasingly elderly population, who have increasingly complex health needs. You might not think this really means that much, but it has a profound impact on how long someone might need to stay in hospital and the kind of care they might require both in terms of social care and health care in the community. A recent report by the King’s Fund showed the extra strain on the health service due to a rise in people having multiple conditions is substantial. (http://www.kingsfund.org.uk/publications/pressures-in-general-practice)
Funding cuts in social care and ‘efficiency savings’ in the NHS are having a terrible impact on hospitals and communities alike. If, as in our locality, wards have to be closed in order to balance the books, this has a massive knock on into several areas. If you close wards, it means the hospital fills up more quickly. If the hospital is full, then where do the patients who need to go into the hospital wait? The answer is in the ED. If they are waiting in the ED, then there becomes a back log of patients who cannot be seen and there will be an automatic failure to see, treat and admit or discharge patients within the 4 hour target window, which then leads to a negative rating for the hospital under CQC and pressure from on high to ‘do something about it’. But that’s just it….what can be done? Can people just be discharged home when they are unwell? – This is happening increasingly and then they end up back in hospital the next day in a worse state. The ED departments get the blame, but there is precious little they can do. At the other end of the line are people waiting to get home, but due to the deep cuts in social care, there simply isn’t the provision to put that care in place and so they are stuck. A lack of joined up computer systems between primary and secondary care makes this even more difficult. And even where patients could be cared for at home by community teams, the correct investment has not been made in this key area, hospital staff have not been trained to work in alternative environments (and believe me, they really are different) and so the teams we need in the community simply aren’t in place in many towns, cities and rural communities.
There is a lack of information flow about patients and the care packages they already have in place and so a massive amount of time is wasted due to poor communication.
The ‘A&E brand’ or ED, as it is now called is incredibly strong. Everybody knows it. And so people use it totally inappropriately, sometimes out of ignorance, sometimes desperation, sometimes laziness or convenience and sometimes apathy to the strain it places on services. We either have to work with this or keep on encouraging people not to use the ED. Unfortunately studies from the USA and Canada show that the more you negatively advertise the ED, the more people will use it. The King’s Fund explain with excellent clarity some of the complexities involved. What’s going on in A&E? The key questions answered (http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters?utm_source=twitter&utm_medium=social&utm_term=socialshare)
Our residential and nursing home sector is in absolute disarray and in some areas of the country they are run like cartels, holding hospital trusts and county councils to ransom in terms of affordability.
We are still unwilling to have a difficult and frank discussion about our attitude to death and how we often keep people alive for years, when we could allow them to die naturally and peacefully (I’ve blogged on this emotive subject previously).

So what happens is we have a circular blame culture in which everybody will blame somebody else, but nobody will take responsibility and so we will continue our dance around the mulberry bush! But if you have just a tiny bit of faith, you can say to this mulberry bush, “Be uprooted and be thrown into the Sea”. Where systems become oppressive and toxic, we must pluck up the complex root structure and find a new way.

Without real commitment from the government to invest rather than cut at this crucial time of transition, spending now to make huge savings in the long term, we might just continue this dance ad infinitum. The solutions cannot deliver change by the next parliament, but the transition must be honoured as vital and therefore allowed to happen over the next 10-20 years. We need a whole systems approach and it needs to involve the following (we’re trying this in Morecambe Bay):
Firstly, we need the development of Integrated Care Communities (ICCs). ICCs are geographically based, multidisciplinary teams, led and co-ordinated by a GP and a nurse but also include the vital mix of the fire service, police, mental health teams, social services, community matrons/long term conditions nurses, district nurses, community therapy teams and representatives of 3rd sector organisations. The idea of these teams to to keep care closer to home, share information, prevent admissions to hospital, but where admissions happen, ensure they happen in a coordinated way, bringing people back home as quickly as possible. We already have some great stories emerging here of this working really successfully. These teams have the potential to change the modus operandi and bring a culture change to how care is delivered.
However, these teams will fail for the same three key reasons the NHS is currently on the ropes. Resource, recruitment and IT.

These teams will be managing complex care in the community. With not too much extra funding, GPs and the care coordinators could do some incredibly effective work, but right now, general practice is at full stretch and so convincing community teams to take on this work will not be straight forward. This resource would be best invested in two areas – recruitment of staff, or retraining of staff and secondment of them from the hospital setting into the community and the strengthening of social care teams, (which to my mind are more accountable and more effective when under the same management as the NHS and provided by the state). The investment in it would also not be huge but it does involve some upfront cash. If each GP/Care Coordinator could have a laptop with Emis Web imbedded in it, with full access to their patients notes, they could go into the hospital setting once a week, do a ward round of their patients, who they know far better than the hospital teams and get them home. With the right team investment in the community this initiative would literally save millions of bed days and save an enormous amount of resource. But the better and more important benefit will be for patients themselves However, there is a warning for the government. In order for this to be effective and have the desired impact, it MUST be double-run, rather than expecting this to be done on top of what is already the status quo. The capacity is simply not in the system, but it could so easily be and this could be utterly transformational.
Secondly, the government must reverse the perverse cuts to funding. It simply bad mathematics to think that you can shrink the size of a hospital and shrink the social care provision available in the community at the same time. We need a serious reinvestment in social care. A strong and well paid social sector will bring more people into work, which btw builds a stronger economy.

Thirdly, we need to ensure all people in residential and nursing care, and those living with complex health conditions in the community have detailed care plans in place to avoid hospital admissions, except when absolutely necessary AND in line with the persons own wishes.

Fourthly, we must co-create urgent care strategies, not designed from on high, but collaboratively between ED departments, mental health teams, the police, GPs, community nursing teams and social services. If we cannot undo fifty years of public mindset about the ED, then let’s work with this rather than against it. We need more people recruited to work in the emergency setting and the pay needs to reflect the complexity and unsocial nature of the work.

Fifthly, we must stop the nonsense around data sharing, make patient records available to patients themselves and front end our EDs, Acute Medical and Surgical Units, Outpatient Departments with the same systems as we find in the GPs, all of whom should agree to share their records. In our area this would be with Emis Web, a very straight forward system to use. It would mean far faster diagnostics, more joined up, effective care for patients and investment now by the government across the UK would save them plenty of money within just a few years. It would also make data gathering, audit and governance easier and safer. The idea of spending literally millions of pounds on apps that can input data straight into patients notes, before we have this far more vital infrastructure in place is quite frankly ridiculous!
Lastly, we must work creatively with communities on public health strategies that can have a lasting impact and so stave off the growing health crises we see emerging for the future.

I don’t know about you, but to me the dance around this mulberry bush has become pretty boring, a colossal waste of time and energy and so in my opinion, we should quite simply stop it and do something different. The solutions are right in front of us. Will the government have the guts to stop what they are doing and make the right investments now for the sake of the health and wellbeing of the population at large and the health and social care system as a whole. They might not get the glory at the next election, but in ten years time, we will see that the right choices were made for the good of all.

Morecambe Bay – Better Care Together

Morecambe Bay

Known for it’s fast moving tides, mud flats, quicksands, islands, rare birds, natural gas, submarine building and nuclear power; Morecambe Bay is a place whose motto is “where beauty surrounds and health abounds”. The first part is true – it is a place with some of the most spectacular views on offer in the entire UK and hidden treasures of wildlife and wonderful walks. A place where I live with my family and I now call home. But it has some of the worst health outcomes in the country, sitting bang in the middle of the North-West – the worst place for health per head of population for any of the regions in the UK. We are the worst for cancer rates, the worst for heart disease, the worst for respiratory problems and the worst for early deaths. And please avoid the rhetoric that would have you believe that it is because of low aspiration and poor choices made by the people here. The North-West is underfunded in terms of health training, according to Health Education England, to the tune of £19 million every year, when compared head to head for other regions. And given the fact that health outcomes are so poor here, it is fascinating that 94% of all health research monies are spent south of Cambridge.

Looking at the health system here, it would be easy to be disheartened. The recent Kirkup enquiry into drastic failures at the University Hospitals of Morecambe Bay Foundation Trust, to which the trust has responded with humility and learning, highlighted just how much change is needed here. We also face the vast complexities associated with local tariff modification. And as if the local challenges are not enough, we have the added recruitment crisis that is affecting the entire country (worse in rural areas), the undermining of our junior doctors and their pay, the berating of nursing colleagues from overseas who don’t get paid enough to remain here, severely low morale in the system as a whole, and a maltreatment of General Practice in the National Press at a time when the profession is on the ropes; then there is the huge debt of the hospital trusts – compounded by the PFI fiasco and the creeping privatisation of our services, which has led to the shambles that is out of hours care and staffing issues due to agency working. And all that is on the background of a hugely underfunded healthservice, with only 8.5% of GDP spent on health compared to the 11% most other OECD countries spend. The truth is, we simply do not spend enough of our GDP on health care for it to be sustainable in its current form, and the government knows this.

For the last three and a half years, I have been working here as a GP, having previously spent 14 years in Manchester. Three days a week, I work clinically in my practice, and the rest of my work time is given over to being part of the executive team for the Lancashire North CCG – I am the lead for Health and Wellbeing. Although the odds are stacked against us, something really wonderful is stirring here. I would go as far to say that believe it or not, Morecambe Bay is one of the most exciting places to be involved in health and social care anywhere in the UK. Let me tell you why I feel so hopeful (and why you should consider working here)!

Understanding the Purpose of Healthcare

A chap called, Phil Cass, who is an (unmet) hero of mine in the medical field, lives in the state of Ohio. He has been been doing some work with local communities to try and make healthcare affordable for everybody – a truly noble quest in a country where 50 million people cannot afford any. He took the conversation out to the community and they tried various questions, but found they weren’t really getting anywhere. He and team of people then realised that they needed to ask a better question. The question they needed to get to was “What is the PURPOSE of our healthcare system?” – Once the communities began engaging with this question, something remarkable happened – time and again, the same answer came through – the answer was this:- “to provide OPTIMAL healthcare to everybody.” The word optimal recognised that every person would achieve different “levels” of health depending on age, underlying health problems, genetics etc, but the vision of the community became that they wanted every individual and the community as a whole to live as well as they could. The community then realised that in order for this to be achievable, they had to fundamentally change their relationship with the healthcare system and this then made care much more affordable. Here in Morecambe Bay, we are taking a similar conversation to the 320000 citizens who live here.

Starting and Finishing with People

The NHS has become a horribly target driven culture and amidst the stress and strain, in which staff themselves often feel dehumanised, it is easy to forget what we are here for – human beings. Putting people (rather than patients) at the heart of how we think about health is a vital starting point.

So, we are learning to truly engage with and listen to the people here. With the help of an amazng team, I have been hosting conversations here in Carnforth, in the form of ‘World Cafe’ discussions (a fantastic way to ensure every voice is heard). Our hope is that from Millom to Morecambe, we will see conversations springing up as we talk about how Morecambe Bay can become the healthiest place in the UK. And by being healthy, we do not mean just physical health. We are talking about mental health, social health (there really is such a thing as society!) and systemic health (including issues like road safety – still the biggest cause of death for our children, the environment and pollution, the real effects of austerity on our communities, the power of advertising and the high cost of healthy food). And as we talk with our citizens, we are not coming in with ideas of how to fix things, as though we are some kind of experts. People are the experts in themselves the their communities, and we have some expertise in a variety of fields. So, we have a meeting of equals. We are waiting to see what rises within the communities themselves and looking to support initiatives where that is wanted. Communities are having some really exciting conversations and some people are standing up to become ‘health and well-being champions’ (the photo is taken from a recent event, supported by our Mayor in Carnforth, looking to do exactly that), who want to help steward the well-being of the community and the environment. It is incredible to see how many people want to get more involved with making this area more “healthy”. Volunteers are springing up with ideas like gorilla gardening, shopping for elderly neighbours, cooking meals for those coming out of hospital, setting up choirs, starting youth clubs, community transport services to help housebound people get to appointments, cleaning up our streets, creating safe parks and being hands on with support for those receiving palliative care. People are learning to ‘self-care’ and care for each other more effectively.

Atul Gawande, another hero, has written powerfully in his book ‘Being Mortal’ (a manifesto for change in how the medical profession deals with the whole topic of death). It challenges the ways in which we don’t face up to our mortality very well. We end up spending an inordinate amount of money in the last year of someone’s life on drugs which have a lottery-ticket chance of working, when all the time, we could help people live longer and more comfortably if we introduced hospice care earlier and treated people with compassion. We are looking to launch compassionate communities here, where we are not afraid to talk about the difficult issues of life. We want people to have the kind of care that allows them to make supported choices to live well, right to the end. Our BCT Matron, Alison Scott, is a true champion of this cause, along with Dr Pete Nightingale, the recent RCGP national lead of palliative care, Dr Nick Sayer, Palliative Care Consultant and Sue McGraw, CEO of St John’s Hospice.

From the moment of conception to the moment of death, we want people to have optimal health in Morecambe Bay. We want people to be able to live well in the context of sometimes very disabling and difficult circumstances and illness. We want to see care wrapped around a person, recognising that this cannot always be provided for by the current ‘system’.

Better Care Together

Before the government launched its five year forward view for the NHS, we were already in the process of learning to work very differently here, around the Bay. We have been blurring the boundaries between various care organisations (including the acute trust, the mental health trust, the GP practices – now forming into a more cohesive federation, community nursing in its various forms, the police, the fire-service, local schools, the voluntary sector, the county council and social services), building relationships between clinical leaders, sharing the burdens of financial choices and care conundrums, strengthening the pillars of the various players, redesigning care pathways across the clinical spectrum to ensure better care for patients and infusing everything we do with integrated IT.

The creation of integrated care communities (ICC) is at the heart of the vision to transfer more care out of the hospital setting and back into the community, whilst ensuring that the funding follows the patient. Our care co-ordinators become the new first port of call for our most vulnerable or ‘at-risk-of-admisison’ citizens. The idea is to wrap care around a person in the community, with the appropriate services being called in. Many times a care coordinator can bring in help from allied professions/volunteers and avoid unnecessary admissions or overlap of services. This means less pressure on the Emergency department and less pressure on General practice. We are also working to ensure our Urgent Care provision is fit for purpose with GPs, NWAS (our ambulance/paramedic service) and Out of Hours care offering much more of a buffer for our Emergency Departments.

Radical Leadership and the Challenges Ahead

There are many challenges ahead and both local and national threats remain. We are steering a huge ship through an iceberg field, and the so the waters are dangerous. We risk a lack of transfer of funding towards General Practice making it difficult for appropriate ‘buy-in’ for the changes we need to see. GPs ourselves have some brave leaps of faith to make. We will not be able to guarantee more money in our own pockets, but we must decide between protecting what we know or federating more fully for a more sustainable and excellent provision of care in the future (providing better education and career development in the process). We risk disengagement from senior clinicians in our hospital trust if the vision is not fully owned and shared by all. We have huge risks associated with the truly shocking cuts being forced upon our county council and a destabilisation of social care. We risk our nursing care home provision causing a halt to the entire program due to the vast complexities involved. Political whims, rules and pressures often seems to knock the wind out of our sails and could still utterly destabilise and destroy what is tenderly being built here.

However, one of the things which I have found most encouraging here is the quality and attitude of the leadership. Andrew Bennett as the SRO for BCT and Jackie Daniels, the CEO of UHMBT (the acute trust), have built stunning teams of people! I have the privilege of sitting on the executive board for the CCG and we have exec to exec meetings with the acute trust, in particular. The truth about Better Care Together is that for some it may mean doing themselves out of a job, letting go of power, and choosing facilitation and servanthood over domination and self-preservation. Leadership that is determined by the future and is able to lay itself down for the sake of what is really needed in our communities is exactly the kind of leadership we need. The leadership here across the spectrum is brave, it is altruistic, it is kenarchic, it is relational and it is rooted in the community.

And so we press on, knowing that we cannot remain as we are, knowing that in building together with our communities, we are finding that the future is not as bleak as it might otherwise be. Together we are wiser, braver and kinder. Morecambe Bay is no longer the butt of the jokes. It is becoming a place of hope, a place of potential, a light that is beginning to burn, dare I say it – a place shaped by love. It will be a place where health abounds in the beauty that surrounds.

Lessons from the Secret Garden

If you have never read ‘The Secret Garden’ by Frances Hodgson Burnett, then read no further, go and read that book and then come back! Seriously – it is one of the most beautiful children’s stories ever told and I have just finished reading it to my eight year old daughter.

It is a story at many levels, but ahead of its time it reveals the power of our psyche in affecting our physical health and how changing the way we think can alter our wellbeing – both physical and mental. Colin, a rejected and yet thoroughly spoilt boy believes he is going to develop a hunch back and die young. His entire life is driven by anxiety of what might happen and a kind of hatred of himself and the world around him. That is until a girl, who was once very similar to him and a boy, who is as free and loving as any human could be, enter his life and awaken the possibility of transforming hope.

I have seen so many patients over the years who believe incredibly negative things about themselves and the world around them. Some of them have evidence to back this up and others most certainly do not. What amazes me time and again is that those who allow their minds and thought patterns to be transformed become much physically stronger and more whole. Those who refuse to change the way they think (because it is actually a choice and a retraining of our thoughts – no one else actually makes us do it) stay as they are and get worse, which always makes me sad. It is not simply about the power of positive thinking. It is choosing to align yourself with a wholly different story, with a different set of imaginings, with hope for the future in place of despair, with love in place of fear.

Colin finds the ‘magic’ that helps him to change. The same magic that causes the plants to grow and the seasons to change; that allows creatures to give birth and the birds to sing their songs. The magic that teaches a boy to walk, a girl to reach out, a hardened old man to cry and a father and son to restore a broken relationship. The magic that allows the place of our greatest pain to become a place of redemptive joy. The magic that allows a human heart to soften and learn to love. It’s what John Newton calls ‘amazing grace’. It’s what I call the Holy Spirit. The dancing One who breaths life through everything and invites us into this same dance. To throw off self-pity and shame and to find life in all its fullness instead. All it takes really is the deliberate choice that we can change and once we open up the possibility, well, truly anything can happen!

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