London, Glasgow and the hospital. (for Sandra)

I remember when I was young, and my brother was getting engaged then married, in the early 80’s.

We lived up in Glasgow and my brother in London.

His soon-to-be wife and her family were down in London and there was an expectation that any events i.e. engagement parties and wedding would happen there.

That is how it happened, and I don’t want to go over what was, the thing however that sticks in my mind, and I can really say this freely now that my parents have gone is the discussion around the travels down South.

In those days I guess it was a bigger thing to drive or get the train all the way from Glasgow to London – it probably wasn’t any quicker than today and it almost certainly cost much less, but for whatever reason, folk didn’t get about as much.

Nowadays when I meet someone who hasn’t been to London, I am a little surprised, although as I have encountered more people and discovered the way in which folk tend to stay where they are, I am finding that this is relatively common.

‘Oh, I’ve been to Sheffield a couple of times,’ Says the Eric, 90 from Barnsley, or, ‘I once went to London, when I was a child,’ Enid, 88 from Rawmarsh.

We tend to think, because many of us get around so much these days that travel is a given, that a familiarity with Oxford Street and Charing Cross Road is what it means to be a citizen.

No.

Returning to my parents, something I can remember my dad saying; or perhaps better, complaining, was the issue of us having to travel down to London for the parties, nuptials, etc.

His phrase was, ‘The journey from London to Glasgow seems longer than Glasgow to London,’ in that, it was OK for us to tootle down the M1 but the reverse was more difficult, longer, more arduous.

I can’t remember whether my sister-in-law’s family ever made it up to Glasgow; I do remember our trips down which were fun. The final one in 1984, ending with my birthday and a ZX Spectrum.

Now, why dig-up old times? Why foray into the past?

Well, it relates to the situation we have nowadays with care in the UK.

There is a sense that it is easier for patients to get to the hospital to see the doctor or nurse than for the nurse to go from the hospital to the patient;

Mohammed must come to the mountain, kind of thing.

Yet, we know that there are far more folk ‘out there’ than in there; also, whilst most clinical people working in hospitals have cars, many of our patients have to struggle with public transport.

Yes, you could argue that the mileage relates to efficiency; there is no way a doctor could see 30 patients in a morning clinic if they had to travel round the community; that is true; equally, I might suggest, if the said doctor or nurse is rattling through 30 patients between 9 to 12 – that is, a patient every 10 minutes without break, is the quality of the encounter not such that it could probably be done another way – on the phone, Facetime, using an intermediary who could perhaps spend longer and liaise with the specialist afterwards.

I am not proposing answers here, just suggestions.

In the local hospitals where I have worked, consultants have special parking places; for they occupy the top of the pyramid. Yes, this out-dated system is still a thing. I remember, leaving my named parking spot in Doncaster with a sense of regret (matched by my sense of pride when I was appointed in 2007 and sent a photo to my parents of the ‘Dr Kersh’ sign).

In my current hospital I don’t park where the special people go – when I applied, there wasn’t room and I wasn’t persistent enough, preferring to throw my hat in with everyone else. I think this democracy is preferable.

And, yet, it does make it tricky at times when I arrive mid-morning for meetings.

Not as tricky as Enid or Eric arriving for their early morning appointment on the bus.

Not everything can leave the hospital – I am not calling for a revolution (well, I am, but not one that involved blood or explosives), we need our operating theatres, our specialised laboratories, but, how much else needs to sit there? How many clinics have to occupy the ivory tower of clinical and scientific remoteness?

I have a colleague who in a very forward-thinking manner, gave-up clinics years ago – his reviews take place in the homes of his patients; albeit working with a team of committed nurses and clinical support workers.

Few people DNA (do not attend) his sessions and consequently efficiency is increased and waiting times reduced.

Working as he does with people who have dementia, is it even worthwhile sending the GP a note – ‘Your patient did not attend the clinic this morning; we will see them routinely in six months.’ Or worse, ‘Your patient did not attend the clinic. We have discharged them.’

How much of this relates to traditional ways of working? Reluctance to change? Perception that me to you is further than you to me?

I think, with all the investment in community care that is promised, will need to be some time spent changing the hearts and minds of the folk who have not ventured outside of hospitals since they were medical or nursing students.

Sure, it is frightening; I am sure when Eric visited Buckingham Palace in 1956 he was a little overwhelmed, but it needs to be done.

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Humanity differing.

One of the most amazing aspects of working in community health has been how I have encountered patients and their relatives.

Now, I have been working with people for a long time – over 20 years and most of my experience as a doctor has been treating, supporting and caring in a hospital context. That is, within the walls of a super-organisation; I was going to write, super-organism and, that is probably also the case.

Once you take people and force them to work together, to collaborate within the confines of concrete and glass their behaviour changes and so too does that of the people they treat.

I’ll explain.

I think I have established over many blogs that hospitals are frequently perceived as places of threat. Whether you are a young child, middle-aged man or in the last days of life, it is, by and large, frightening.

Sure, the staff are kind (although I appreciate not all necessarily come across that way at all times) and the whole purpose of the place is to heal, cure or treat; yet, frequently this isn’t the perception.

A little like airports.

People coming and going; a major difference being that the destinations and arrivals are often opaque in hospital, the duration and number of stop-offs frequently not revealed until it is too late.

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When I go to Heathrow, I have an app that tells me where to go, what to do and how; I am sure that some hospitals in the UK have an app already that tells you about your visit, your appointment and so on, yet, given the financial situation of the NHS, only tiny amounts are ever invested in communications or graphic design – despite the NHS having loads of money, things don’t always flow where they should.

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In the past 10 years hospitals, in my opinion, have become more frightening – even the issue of car-parking, ever the bane of a Chief Executive’s existence has become a major impediment. If you are in Central London (where the decisions are made), you are OK, the further away from the centre, the more rural your place of residence, the harder. And often the more expensive.

Whether or not you have the stress of parking (I won’t even mention the stress of waiting to be picked-up by hospital transport – early rise, waiting for the door-bell, getting your stuff), navigation is mostly tricky.

There is a whole science of finding your way, the simplest being sign-posts and arrows, ideally alphabetised. I haven’t encountered a hospital yet where this is sorted.

You worry about arriving early for your appointment, know you will wait, or you might be lying in an ambulance outside A&E for three hours or a stretcher in the hospital waiting for a bed and all of this going-on when you are either worried, ‘Do I have cancer?’ or unwell – sepsis, infarction, inflammation.

Observing from the outside it might appear as a macabre game of survival of the fittest.

All of this leads to an effect on people.

It increases their level of stress.

Fascinatingly, the staff who work in the hospital, although stressed because of other things – shortages of staff, bullying managers, don’t perceive the environmental or situational stress of the appointment; they know where to park and the location of the toilets.

Not the patients.

Unfamiliarity leads to worry.

Encountering a patient, carer or relative in hospital is a situation where there is a power imbalance – me doctor, you patient, either with the professional hierarchy or one based on knowledge alone – I know what is wrong, or I think I do, you are lost.

This imbalance worsens the stress, combining it with fear and the lizard-brain kicks in, often shutting people-down, creating either submissiveness, passivity or aggression.

You see, the wonder of the community is that this is mostly absent.

Sure, a visit to the GP or to see me at the surgery might be stressful – getting time off work, or someone to look after the children, for example, yet, the location is usually familiar, so too the people, the staff.

When I visit someone at home, and they are sitting in their favourite armchair, the lighting just right and if I am lucky, dog by their side, the encounter is different. The fear is absent, or if present, quickly ebbs.

I am relaxed, as is my patient and their son or daughter. I am the outsider here, coming-in as a guest through the unlocked door into a world which is familiar to them.

There is a misconception within healthcare (you’ll note I haven’t said health and social care, as I believe this is mainly a clinical thing), that the sick people are in hospital.

Yes, this is the case.

If you go to intensive care or high dependency you will meet some very unwell individuals; those on ventilators, inotropes supporting their blood pressure, wires and cannulae into every opening.

Yet, the numbers are usually small.

An average hospital might have 20* or so such beds; the rest of the patients have varying degrees of illness, with a huge number in hospital beds because there is no other place for them (community inadequately funded often to attend to their needs).

At the same time, out in the community there are perhaps five or ten times as many people (aka patients) who are equally and often more unwell, being treated, supported and looked after in care homes and their own homes. Their numbers are hidden as NHS priorities find this hard to represent; the front-page image of ambulances queuing outside A&E is not easy to translate into a front living room converted to a treatment area with round the clock support provided by community teams and families.

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This week in Cornwall, the main hospital in Truro called a ‘black alert.

Another way of putting this is that the care that exists in the community – including the work of GPs, community nurses, therapists and pharmacists hugely dwarfs the amount happening in hospital, yet the budget is just as disproportionately weighted;

I read recently that the budgets of the eight big hospitals in London are equivalent to all the money spent on community care in England and Wales.

I might be getting away from the point, but, I think essentially my message is that hospitals serve a purpose, but that has all become misaligned in recent years and convoluted by people doing what they have done, maintaining traditional ways and working practices.

This blog was going to start with my mentioning the spiral. To those of you who have been reading, the fact that I have only mentioned this now is probably a relief (although not as good had I left it out altogether), yet, the next stage to discuss was going to be blue; this is hierarchy, organised religion, systems and processes – military or regimental order.

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Some people think the hospital can function in this way; ensuring that every box is ticked, and all numbers are rounded up to the nearest decimal point. There is no room for fuzziness, which might be translated into person-centredness, for people if they are anything, they are sometimes a bit untidy, a bit of a mess.

I will explain more in a later blog.

For now, I’d like to reflect on the stunningly, overwhelmingly positive experiences I have had since working in the community. The laughter is often infectious, the smiles, the warmth, the thanks. Mutual respect, kindness and caring. Fascinating insights into the lives of people who have lived for 90 years and more, moments of grace where mother and daughter hold hands, or old dog’s tail wags at his owner’s voice.

Will it ever be possible to improve the hospital situation – to make it more like home and less like a thing?

It is hard to imagine, so long as the staff in hospitals are treated themselves like pawns in a game of command and control.

It is the aspiration to make the hospitals look clinical that makes them alien;

When a surgeon is poised over my broken hip I would like that clinical sterility, that void of softness; yet, for that surgeon to function in a team, with people, peers, they need the kindness, caring and empathy of the group, the ability to be told-off for a silly mistake or mis-perception; ego can’t be allowed in.

Maybe it is an ego thing.

Perhaps, and, also something related to experience.

Most doctors and nurses working in hospitals have minimal exposure work outside the confines of the walls of the institution. Have never been to a patient’s house, have never sat in general practice and listened to the interactions or observed the variety of experience that is routine for a GP or practice nurse.

There is an aspiration for more medical and nursing students to spend time in the community, to learn the lessons of person-first, yet, our society still sees the hospital as the place to go, it is still caught in a 1950’s romance with what the NHS was meant to be.

The NHS is, and it is very great, amazing, it just seems a little uneven at times.

I wish that every doctor, nurse and clinical worker could experience the enriching experience of asking a patient, ‘What matters to you?’ And, having this followed-up with an action plan that is not based on their perception of what I think should matter – again, that fear divide is diminished in an untidy bedroom;

Perhaps with the current plans to divert money into community services we will see this change; equally, the nightmare might happen, and we will turn the community into a hospital without walls, with all the bad aspects and none of the organisation.

We don’t want that.

It seems so easy, so straightforward, for people to respect one another and listen; pay heed, attend with sensitivity, openness and honesty. There is no place for fear in growth – that just stultifies and entrenches.

Let’s keep inching forwards.

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*4000 critical care beds in England vs 130,000 acute beds.

 

 

Money is indeed disappearing

I don’t know what it means, the disappearance of money.

In many respects, this is great. The shift to non-paper and coin-based transactions.

Tap and go.

Contactless.

No worn-out trouser pockets.

I think of homeless people and wonder how they will get by; last week I saw a busker at King’s Cross Station – he had a contactless one-pound payment machine – I guess that is the future.

It is acknowledged that it is much easier to spend money when you don’t use cash; money from credit and debit cards bypasses that part of your brain which urges restraint (mix this with alcohol and anything can happen). When you don’t even have to type-in (or remember) a PIN the likelihood is, the gates will swing open more widely. This is ace if you are a retailer, supermarket or clothes shop – I don’t know how the Salvation Army will make ends meet.

I don’t really want to venture into the debate as to whether homeless people should be given money; I am far too ignorant of that world to discuss. It is however a reality that you can nowadays honestly say, ‘Afraid I haven’t any change,’ without fibbing. You can even feel good about yourself, you run the internal dialogue, ‘Well, if I had a few quid, I’d have given him some, but I don’t, I just have cards.’

I am sure the manufacturers of contactless payment systems were just looking at a means of increasing efficiency and convenience for consumers, it isn’t clear what impact they will have on those selling the Big Issue or playing accordion on the high-street.

Today I observed something else.

I was standing next to a guy; I don’t know if he was homeless although he had asked me for change, as I answered apologetically that I didn’t, he then asked the next person walking past only to apologise himself, half way through the request when he realised that that guy was homeless too. (As to whether the second guy was pleased he was mistaken for someone who wasn’t homeless, I don’t know.)

Again, I am saying homeless; I don’t know if this is the case. There is a certain street-hardiness that people who ask for money have; often dirty hands, tanned faces and a look of despair and bitterness.

I guess life in many respects is getting harder for everyone; the cost of living rises as does inflation and wages stagnate. Austerity miniaturises the state’s largesse and we all look to an uncertain future. You could argue, if the world is shrinking, why should those seeking charity be left-out.

What a rubbish situation.

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The Robber’s Cave

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I first heard of the Robber’s Cave Experiment in Don Beck’s Spiral Dynamics book (people are sighing, no more SD… Again, bear with me) – I didn’t know at the time what it meant although as it had such an intriguing title – made me think of pirates, smugglers and caves (a weird cocktail of Enid Blyton and Pirates of the Caribbean) I made a mental note to investigate; I came across the term again yesterday and read more.

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Unfortunately, it has nothing whatsoever to with robbers or caves although the reality is far from mundane.

In 1954 two American Social Psychologists, Muzafer Sherif and Carolyn Wood Sherif took a group of young ‘normal’ adolescent boys and split them into two teams; each not knowing of the others’ existence; the venue was the Robber’s Cave State Park in Oklahoma.

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Essentially, they showed that it is quite easy to get disparate groups of people – the same applies to adults as children, and combine into a teams that compete, especially when there is limited resource or a solitary prize; the camp ‘supervisors’ who were psychology students oversaw and manipulated the situations.

Very soon after the initial group forming and norming – that is acquiring their own identity and set of particular behaviours and beliefs, perhaps team name, symbols and leader, they were launched into competition with the other group.

Rapidly divisions arose between them and us and just like our current political divide people argue and fight over even the most trivial of things; my vote or yours, my opinion, my way or the…

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Humans have an incredible ability to group – this is our social, gregarious nature and equally, once that bond is formed it can be stunningly powerful, enough to keep people together even when they realise that they are either being manipulated (Brexit) or don’t want to continue.

A few blogs ago I wrote about the second level of the spiral – purple, this is the level of tribe and compared this with the Jewish sanction of excommunication; of pretending as if the person who is your son or daughter, husband or wife no longer exists and this being in many respects a punishment worse than anything and sufficient to maintain the in-group and order through the most restrictive and difficult times.

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In the two groups they subsequently learned that the only way to restore cohesion was not to just force them to share the same accommodation or play together, but to generate a common goal, one which could only be achieved by collaboration – for example, an existential threat has the ability for people to put aside their differences and get on with things.

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I was talking recently to my son about this; his cynical interpretation was, ‘Should we have another World War?’ – given that WW2 has led to the longest period, in modern times of global peace and prosperity we have known (so long as you aren’t in one of the countries neglected or manipulated by the West.)

Unfortunately, or gosh, fortunately, war is no longer feasible; at least along the lines of 1914 or 39; we would very quickly destroy everything, we use battles of words these days which are far less harmful (mostly), yet, they don’t have the value of bringing us together – even, the threat of Climate Change has still not penetrated the thick skulls of some national leaders (what more do they want?)

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It was my friend Claudius who made me consider the current UK political situation in this light; we have Left and Right, fighting, squabbling, in ways that would be embarrassing were they children when the super-ordinate goal (the big one that unifies us) hasn’t been defined.

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Part of this is perhaps the times; for although we (citizens of the UK), the fifth largest economy in the world have some of the greatest deprivation and variations in life expectancy the general theme is we are OK.

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I saw a kid crossing the road yesterday; smartphone in hand. It struck me that I have noticed far fewer crazy teenage jay-walkers recently and it made me wonder whether the fear of having their phones damaged has made them pay more attention to the world (when the machine itself hasn’t taken over and absorbed them wholly at which point anything can happen). The addictive phone moment is the Opium that was once religion.

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So long as the material flow of things, either in cash or on credit continues we are unlikely to feel a significant pinch; like the boiling-frog concept, time passes too slowly for most to notice.

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Before we know it, October 2019 will have happened and nothing has developed or changed, we are still as divided as in 2016 (the UK that is), despite the reality that we are en-masse participants in a Robber’s Cave Experiment that is UK democracy.

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We prefer to fight and disagree than collaborate;

What will it take?

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In the Robber’s Cave, the kids came together in the end by finding a goal that could only be achieved in collaboration – as a team and it is just as likely that society will only progress if we (that is people, UK citizens, Europeans or whatever) find a similar goal – realising that division tears us apart and no one can win at such times.

This does all relate to the spiral and I will return to explaining/defining the different levels shortly; for now, most people still I imagine believe that I am investing in Cloud-cuckoo-land.

There is a point to all of this.

I promise.

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You can see a film of the study here.

I veered into Yellow

Now, it is highly likely that this series of blogs on the spiral or, the emergent, cyclical, double-helix model of adult biopsychosocial systems development will damage any progress I have made in acquiring or retaining readers.

In an earlier posting I quoted Steve Jobs with his saying that simplicity is the ultimate sophistication; this is true of everything. The simpler the argument the deeper the truth and I worry that by sprinkling these seeds, across an area of which I am at best a novice I’m doing harm.

Yet, I can’t stop.

I can’t help myself.

From what I have so far taken away and understood, it has provided me with an insight into life that surpasses anything I have read or learned yet – putting Jesus, Freud, Marx, Darwin aside, Skinner, Berne, Rogers and the rest. It provides a  useful lens through which to view people, behaviour and society.

I will therefore keep going.

Hopefully my introductory stories will help.

How did I veer into Yellow (yellow?) today?

Yellow is not the next stage of the spiral after Red (?red) which I described on Tuesday night; indeed there are three levels in-between which each need explaining in their turn, yet, sometimes it is necessary to jump ahead, to get an idea of where you are heading.

What is yellow?

Yellow is the developmental stage after green, which follows orange and blue.

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Why am I focusing on yellow? Well, according to some theories it is the highest level represented within organisations or systems in the world today (there are levels of development/evolution after that (turquoise & coral), but the exponents are supposedly lone-wolves within the realm today of prophet/madman/philosopher).

So, yellow.

It is also called ‘integrative’

It is where the level of human development is such that the complexity (or I guess, simplicity) of systems is self-evident; you see your destination and intuitively perceive that the way to arrive at that goal is not straightforward, indeed, you might learn that it is only a stepping-stone towards something else. You stop sweating the small stuff to use a business cliché.

How did I veer into this today?

Well, I attended an impromptu meeting with several wonderful colleagues to discuss a new innovation in education and training called ‘Project Echo’ – this is a global initiative based upon sound educational theories which aspires to spread learning and share good practice in an effective and cost-efficient way (using technology) amongst the greatest number of people possible.

The medium used is Zoom – online conferencing, although the technology is only part, it is pivotal; it is a platform that enables people to log-in to a lecture/discussion, I believe they can accommodate up to several hundred participants at any one time; the session is led by a facilitator and a presenter or subject matter expert provides a short, say 20 minute talk on a subject and then there are some other shorter discussions or presentations from those dialling in (who through the project function as a Wengerian Community of Practice) to share, broaden and perpetuate the learning; questions, answers and discussions then follow.

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The result is an educational experience that can be accessed by anyone, anywhere;

So far, some of the hardest to reach groups in health and social care have been paramedics and care home staff; the former because they are always out and about saving lives and the latter because of the market model within which they exist (where education is not seen as important) and their dispersed geographical nature.

Ideally if you are an older person living in a nursing home and you are sick you would like to be tended by a carer who calls a paramedic, both of whom are up to date with all ideas and theories of treatment and support; unfortunately, in part because of our government’s obsession with austerity and societies norms (likely to be different in Norway or Sweden for example), education has frequently been squeezed to the margins and does not feature, often at all within the working lives of carers and only at great expense to paramedics, nurses, doctors, and all the others providing care.

Zoom is a way around this; you can sit in an ambulance at the depot and using your phone Zoom-in to a talk, the same can happen with a carer, social worker or pharmacist. None of them have to travel to a central venue for hours of didactic training that they forget on the way home. The training comes to you where you are, so long as you have Wi-Fi and a smartphone, laptop or tablet.

I have perhaps not done the ECHO system justice in my explanation and that is not really the point, more, the people in the room – there were five of us were all first passionate about care in its broad and deep sense and secondly, intuitively, took a humanistic approach to learning, in that people don’t learn because they can’t be bothered, indeed, most people, are hungry to learn so long as the experience isn’t painful (not boring, ineffective web-based click-throughs with tedious presenter for example) and is not inaccessible – you have to travel from Newcastle to London for a few snippets of irrelevant information at your own cost.

ECHO is 21st century in the way that Uber, Air B&B, Google and Buurtzorg have adopted technology and evolving human behaviours and patters of action; it could be a way to revolutionise all of training in health and social care (acknowledging that there is more than this, hands-on and face to face is still necessary, it is just that these are far more effective if you are hands-on with someone who has a basic appreciation of the theory beyond a textbook they have skimmed the night before).

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Heck, this might even mean the end of my lectures on older people.

And back to the yellow.

Yellow is integrative, it is seeing that, just as the IHI’s Quadruple Aim of improving quality and accessibility at cost is noble, it is only feasible if you care for the carers, if you find joy at work and ensure that staff are not falling-down; look after the staff and they will want to care, neglect them and they will become exhausted and burnt-out.

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I read yesterday about an old Croatian saying – don’t pay all your attention to the plant; support the soil and fruit will grow. You can build a palace for patients but if the staff are absent the care can’t happen.

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The group all saw this intuitively.

There was rapid discussion and sharing of ideas for even though most of us had not met before, there was a shared, intuitive understanding of what matters, or where to focus; a mutual respect for the limitations of time and a passion for pushing through to do something that will influence change.

Ego didn’t enter the room.

Nor did self-interest, bravado or showmanship.

It was passion for care, raw in tooth and claw.

This is yellow; where people are able to understand that you can’t have winners and losers and still succeed; the only meaningful success is through mutual progression. We consider the planet, the wellbeing of our teams and our patients, we even take into account the needs of our masters with their budgets and targets to reach.

It becomes like a powerful game of chess where the moves seem to happen independently in a preordained, synchronous fashion.

I doubt I have done my meeting justice and I strongly suspect this blog will have confused more people than anything; apologies. This will make sense in the end (or now, if you have the DeLorean).

Thanks for listening and have a good day/evening.

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Spiral #5 (red)

I may be crazy, but I thought I’d have a go at winding down tonight by continuing my spiral series.

I have an interview tomorrow, in London, and, as I never know either where to begin with preparation for such events and frequently come-across as a stressed-out mare, I thought I would spend my time doing something productive rather than fretting.

Here I go.

It is funny.

Earlier today I had another foray into the spiral.

As I have already explained, this may not make much sense to people unless they are already familiar with the theory or have read my completed sequence of spiral documents. (Yet to be written, so for now are also time-travellers :-))

I’ll give you a flavour.

Essentially, me, at work, in a meeting, trying to explain why I work best when supported by kind, caring, considerate people and allowed a degree of freedom to innovate and create.

It’s not that complicated.

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Pick-up any modern book on management or leadership and the first chapter will explain that the way to encourage productive employees or workers is to first see them as people, then play to their strengths and afterwards provide a smidgen of person-centredness and voila, magic happens.

The NHS has always had a struggle with this and I believe it is at the centre of many of the challenges we face – for example, we have literally a whole generation of baby-boomers who have taken early retirement because they have become so alienated from work; doctors, nurses, therapists leave work at the first opportunity to spend time with hobbies, the family or grandchildren, not that there is anything wrong with that, but, our society needs them as doctors, nurses and therapists – we have made the environment so hostile that the joy of work is seen as a paradox.

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Enough of that.

The third tier of the spiral is the phase in human history – supposedly around 10,000 years ago when we moved from living in clans and found ourselves dragged-in to empires; the rise of super-tough hierarchies with absolute leaders.

If you ask Dan Carlin for his favourite, I am sure he’ll say Genghis Khan (if you haven’t listened yet, please do ‘Wrath of the Khans’ says it all) – there were Julius Caesars, and Alexander the Greats.

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You didn’t mess with these guys or their followers, and, consequently they ruled the world, or what was known of it at the time.

Why should we worry about those old kingdom-builders from the past? Well, just as with the two earlier parts of the spiral, beige (family/survival) and purple (clan), the sentiments are still very much around today.

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As previously described, these stages don’t spring from the thin-air; they are passed-down as memetic inheritances (memes – for more, see here).

Has the age of empire gone?

I don’t think so.

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Mr Trump would probably say that his is the best there has ever been; Mr Xi Jinping would likely disagree. Is it the number of cultures you subdue, subjugate or rule that matters or money in the bank? Are Sergey and Larry emperors? What about Zuckerberg – do the rules apply to these guys?

And, even if you are not megalomaniacal enough to place yourself at the head of a multi-national, what about the corporate oligarchs who are indeed a people apart – who have existences and means of influence that are beyond the imaginings of most of us.

Yes, the one per cent rules everyone else, but what about the few at the very top. Are they in charge? Who is?

In the olden days, threats to the ruler would usually result in either a swift or slow, very painful death (to you and your family or clan) – this is not the situation nowadays, but cross one of those guys and your suffering (interpreted through the medium of law-suits) will fix you.

This system is alive and well in people who at different times might have risen to prominence; when they are in the workplace or school or university, their tyranny is expressed on a smaller scale.

And, just as I experience the beige and the purple (I am not immune from worry about family, shelter and what people think of me), I also have a little red. It doesn’t appear very often, indeed, it is tucked away in a vestigial part of my soul I haven’t yet discovered, but it is there.

I remember an experience many years ago when working with a group of clinical staff. These guys were high on the barometer of caring – their daily bread was supporting those at the end of life; archetypical angels.

Yet, when their values were challenged (not by me!) they became quite fierce. Powerful, careful, cunning, ferocious.

We all have this switch.

It does well to be aware, to pay attention to the possibility within each of us, for as with the others, this is a way to exert control. And, equally, to understand the position of your friends and enemies, their stance from a place of fear, usually predicated upon a past of bullying or childhood upset. You don’t have to go out of the way to feel sorry for these folks, although it might help you cope when things get tough.

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Spiral (4)

I had some feedback about my recent spiral blogs… We thought you were losing touch with reality… going mad.

Well, I don’t feel crazy; indeed, for whatever reason I have lately felt quite grounded.

Sure, reflecting on an obscure theory of everything is a little odd.

Nevertheless, I plan to keep on until it is done!

I have covered the first tier of the spiral.

That was level one.

The basic unit of organisation.

The family.

The essence of survival.

It was particularly fascinating for me as, the other week I was in Israel on holiday; I toured the North with my son, passing through not so much phases of the spiral but different cultural and developmental states –

Here are a few;

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Bahai Gardens, Haifa

We met Palestinians, Israelis, Druze, Bahai’s, Arab Israelis, Russians, Americans, Kibbutzniks and fellow holiday makers, we saw ancient monuments – in Nazareth, for example, where Mary is said to have met Angel Gabriel, up mountain tops into disputed international territories on the border or Lebanon, Syria and Jordan.

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The colours of the spiral developed during Beck’s work in South Africa with De Klerk and Mandela through the dying away of Apartheid. The Rainbow Nation that evolved was a place where colours, races and identities were put to one side in favour of rebuilding a nation based on principles of equity and equality.

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Hermon heights

I don’t want to get bogged down in politics – that is perhaps something that can be discussed and analysed when we have covered all the different tiers, for now, let’s get back to business; tier 2.

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Nazareth

After the family, what is there?

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Church of the Annunciation, Nazareth

How do we organise once mum and dad, brother and sister are in a stable state of being? Once there is a semi-permanent shelter and adequate food to sustain?

From here we move to tribe; clan. Second then third-degree relatives. Everyone knows everyone else; business is a collective affair and every effort is invested in maintaining the integrity of the group. Finding yourself an outcast is a death sentence.

In the Hebrew days of tribe, breaking a law resulted not necessarily in physical punishment but a collective turning away of the group; you would become invisible, ostracised, ignored, your past and present wiped-out. This to many is a fate worse than death – deletion.

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The clan is held-together by ties of blood and rituals, rites of passage, dress, language, culture and song.

This is Maslow’s second level, where I can sleep through the night because someone else will be looking-out; I can hunt, study and spend time developing my skills as every moment is not caught-up with survival.

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The success of the group is dependent upon everyone following the same lead, adopting the same customs, beliefs, thoughts. Attempts to disrupt the clan are perceived as an existential threat.

This level has the colour purple, which as with beige and all the rest is arbitrary. It just is a nice colour. (Supposedly, a warm colour as it is looking outwards to the group, at us, rather than the more inward beige of individual or personal survival.)

What does this tier mean? What is its significance or relevance to us, today, living our complex lives?

Well, here is a thought.

We are all still often stuck in tribe-mode.

Us versus Them.

I remember when I worked in Doncaster, being part of that tribe, and with my shift to Rotherham and my change of position, the altered relationships the change of status;

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Although I was oblivious, my tribe was Doncaster then it became Rotherham, I was at first confused. I felt I was acting in the best interests of my patients, many of whom do not identify with the Doncaster, Sheffield or Rotherham tribe – if anything, logistically they might say they are from South Yorkshire, but that was not how the tribe (hospital trust) behaved.

It became us versus them; a competition for resources, doctors, nurses, pathways and investment.

Is it not fascinating how such complex systems – where surgeons, psychiatrists and scientists dissect the innermost essences of molecular biology, technology and emotion, accountants and managers analyse spreadsheets and tend unbalanceable books that there is a reversion to this primitive state?

How sophisticated do you need to become in order that the possibility of reversion is gone? Perhaps never. Always a good lesson when we are getting ahead of ourselves, in a position to look-down on others for their manners, behaviours, prejudices or beliefs.

The value of the perception of this stage in the evolution of society?

The value is in the awareness.

The best way to avoid a trap is to be aware; sure, this doesn’t mean that you can be safe in every situation, it just adds to the likelihood of early recognition.

A question we should perhaps consider whenever we perceive them and us – when our defences or hackles are raised – Is there really something to fear or is it just fear that is perpetuating the situation?

And once we gain recognition of the tribal lapse, it is perhaps only then that we can work better together in collaboration, in harmony.

Am I a bad doctor?

You see, the problem is that I don’t really do data.

There are some doctors who are able to quote you the statistics relating to different tests and treatments; numbers roll of their tongues; like silken numerologists, they are able to say… the p value is below the level of significance… or, the 2012 study in the Lancet showed the non-inferiority of x over y.

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I have never been that kind of doctor.

I am sorry.

I don’t know if my inability to recall such information has resulted in any direct or indirect harm to patients.

I am not saying that I don’t know my stuff, it is just that when it comes down to numbers I am often at a loss.

The reasons for this probably relate more to my perception of doctoring than an inherent inability to count – although I was never a natural at maths, more the realisation, or, perhaps, my perception that numbers don’t really matter.

I know, in the days of evidence-based medicine, this is probably enough to get me struck-off, but there you are. Beyond innumeracy, honesty is another flaw.

You see, I have always felt that in these studies, the ones that really count, what the number-guys call ‘statistically significant’ require so many people that the individual is usually lost.

Sure, if you have medicine A and two people take it and one person lives and the other dies, that is something, but it could be chance; if 20 take it and one dies who would otherwise have died, that is statistical significance. It’s great, unless you are that one who dies.

We aren’t meant to mix our statistical metaphors, yet, I can’t help myself.

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To me, a patient is a patient and moreover they are a person.

Unique, indivisible.

A one-off.

They are that one who lived or didn’t.

Sure, in these days of economics and large-scale change we need to look at populations, we need to be sure that the money is invested in the right places, again, that doesn’t help Doris, struggling to reach her front door because the Zimmer-frame is slightly too wide for her doorway.

It is all the individual.

The person.

That is perhaps why I have become so mesmerised by the work I have recently undertaken; the shift from hospital, where the buzz, the chaos, the insanity of percentage bed availability, national targets and waiting times rules, to the community, where it is me and my patient.

We sit one on one, confidentially, quietly, our time is ours and we can concentrate; there isn’t someone listening-in behind the curtain in the next bed, their bottoms are not exposed, there is a sense of the importance of the individual that hospitals struggle to contain.

My mum’s old catchphrase from her many visits to the Southern General and the Vicky in Glasgow was, ‘You leave your dignity at the door,’ I never really knew what she meant until I became a doctor and saw the goings-on.

My family at the moment is caught-up in a healthcare ?mess. A 90-odd year-old relative has been stuck in hospital for over two months after falling at home.

Last night she fell in the rehab hospital and was taken to the nearby A&E for assessment; I can picture the scene – Saturday night chaos, stretchers, desperate staff and patients all doing their best; radiographers, porters and healthcare assistants battling, an old woman amongst many waiting, waiting.

She was discharged and returned to the rehabilitation ward at three in the morning; after finding the front-doors locked and gaining access she and her daughter found that all her belongings had been bagged-up;

Managers looking at efficiency, focused on length of stay or bed occupancy rates would potentially be delighted at the efficiency of the service – no acute admission, no bed taken-up, even for the few hours she was in the A&E limbo she wasn’t even an inpatient.

It is this dehumanisation that makes me afraid of the numbers.

For me, it is one person at a time.

Moments pass and it is still the same person.

Their suffering, their experience is that of the individual.

The indivisible person that is not a statistical fragment, a shard of data.

And so too the staff who bend under the weight of the pressures placed upon them, where often it is easier to go along than challenge, stand-up to the bed-manager who at two in the morning is chasing their own tail.

The dehumanisation of healthcare that starts with the data-mongers ends with little a old man or woman, young doctor or nurse, stripped of their identity, boiled-down to happenstance.

Perhaps I should take pride in my resistance to the numbers.

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Should I lose the Lycra?

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This morning, out with the dog I considered whether I should get rid of my Lycra.

Nothing fancy, just some running shorts and t-shirts. Mostly from 15 years ago, the year my son was born, and I ran the Sheffield marathon – the one that resulted in multiple hospitalisations because of the extreme heat and the hills.

I have struggled with running ever since, gradually allowing myself to deteriorate, participating in the odd half-marathon, all the way to my current walking.

Now, walking is a good form of exercise – so long as it’s brisk and of sufficient duration.

We’re not talking speed-walking here, more, a pace that gets you places.

This form of walking generally requires boots and whatever the weather dictates – t-shirt and shorts or raincoat; it can be done every day and there is no Lycra.

Yet, I still have my Lycra drawer.

Somewhere inside me is the notion that I might get back to the heady heights of five-hour runs across rough ground, when I would sup from my Camelbak in the runner’s high.

I used to get injuries too; sore ankles and knees. I am not a natural aesthete – my body shape is I believe more adapted to trekking across the desert than running in the high country.

Walking has not ever, as far as I can remember injured me.

The bike has resulted in fractured skull and arm, the running, bursitis and torn muscles, by comparison, walking seems benign; it is also a good way to spend time with my dog.

I am not trying to sell walking as an activity, although I suspect if more people got out there, the world would be a happier place.

My kids joke about the mamil’s as they cycle past at the weekends.

There is less of a risk of fashion faux pas in non-Lycra activity.

I am not suggesting there is anything bad or wrong with the stretchy fabric, it is more that I am feeling my age, with the realisation that a more sedate activity is likely to allow me to keep going for longer; my days of sprinting are gone.

It is true, if I refer to the literature that there is no too late age to start running, cycling or serious outdoor aerobic exercise; I suspect some of this reflects the stage a person reaches when they realise that who they are is what they are and the future is likely to remain stable – I don’t mean life, that will surely continue to oscillate, no, who I am, my shape, size, physical and physiological dimensions are pretty fixed, now and into the future, and, likely the Lycra can go, and make room for something else.

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PS Photos from this morning’s walk.

Spiral 3 part 2 ½ (the one with the monkeys) & the ultimate banana.

I was going to write about monkeys, Planet of the Apes and Spiral Dynamics.

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Afraid I am a little too hay-fevered from early morning walk with dog;

In the meantime, here are thoughts on bananas –

I feel that of the fruits, bananas must be the loneliest.

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In a bunch they are OK, but when left to the last one, it must be grim.

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You see, bananas as they ripen release a gas called ethylene. This causes other fruit to ripen as well and ultimately spoil. To avoid this we tend to isolate them.

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Keep them away from the oranges, apples and nectarines.

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It must be like having B.O. or scabies.

There are special banana hangers that can allow you to suspend them, hence reducing the concentrating effects of their gas; that still doesn’t help with the last one. An apple or orange can always find a buddy, not so the banana.

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(Kiwi are also bad ethylene producers, but, for whatever reason, a little like the popular kid at school, who despite having a smell or some other negative association is somehow immune, and people choose to ignore.)

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Damn those kiwis.

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the sea

Sitting, waterfront veranda over the Sea of Galilee, called Lake Tiberias, Ha-Kineret in Hebrew or Bahr Aljalil in Arabic; I hear wood pigeon and sparrows. A generator in the background mostly slips away as I stop listening to its drone; the sea is calm. The water, a black mirror reflecting a rising sun, which itself is hidden behind early cloud. Ripples in the water are fish surfacing or the occasional swallow skimming the surface.

Ginger cat prowls.

Fishermen call.

Old man gathers cans for the 25 Agura deposit.

A mynah sits in the bougainvillea.

Municipal worker throws scraps to ravening shoals of fish; he gathers the crap that people haven’t bothered to place in the bin; he to me, is the holy one.

Yesterday I swam in the water; speckled algae green and gently lapping waves.

The sun is starting to break-through.

The heat will shortly be upon us.

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Spiral (3)

I don’t know whether I have done justice to what is called the first tier of the spiral.

I keep an eye on the numbers of people reading my blogs and I know that the past couple have not gone down very well; partially because ‘spiral’ doesn’t mean that much and equally I guess, as it is potentially quite a turgid topic (to some!).

How to reconcile?

Part of the reason for my blogs, which have been going-on for over four years, has been to express what is in my head; to put down in binary-code my impressions of the world. And, given this, the spiral (should this be ‘Spiral’ or ‘spiral’? I don’t want to give too much credit or attention to something that is equivalent to ‘skeleton’ – it is the human and their humanity that matters, not the structure) (I’ll go for spiral).

Sorry… to continue! The spiral is and has been occupying my thoughts recently, particularly as I travel round Israel with my son, seeing people who appear as such stark representations not necessarily at different stages of the spiral (of which I promise to say more), but who dress and behave so differently – here are some examples;

Israeli schoolchildren on day-trip; each with sun hat.

Arab schoolchildren day trip, hatless and happy.

Jewish schoolgirls, hatless, stocking tights, trainers and loud.

All groups happy, exuberant.

Jewish men, tzitzit, stripped-off before plunge into the water.

Arab man, casual clothes, T-shirt and jeans.

Muslim woman, head to toe covered-up.

Homeless woman, hoodie and black feet, shop vendor, fisherman, Greek Orthodox priest – you name it and it is here; shirtless Israeli, early morning health-walk; over-loud American Bar Mitzvah party, celebrating with fireworks. Arab man tossing bread to hungry fish as his grand-children laugh.

A complex harmony.

And, given that everyone is getting-on; no one is fighting, just calm and peace, it does feel a little, not necessarily like a spiral, but an organised representation of who we are.

Differing points of view, styles of dress, talk, language, all, occupying the same space.

Self-organising.

Superficial simplicity and internal complexity.

Has any of this helped?

As the blog is and hasn’t served any purpose up until now other than me expressing myself, I suppose this hasn’t done any harm. It is likely that this is less confusing than the initial spiral foray; there you go.

Back to the spiral.

I don’t feel I have done justice to the first rung.

So much has been written about teal and all the rest, I believe the early stages have been neglected.

(Oh, just to re-emphasise before I leave this for good; this is all just one way of seeing things, it isn’t the way.)

Echoes of Bruce Lee.

It is like focusing on the top of the pyramid and neglecting the base, where all the pressure if concentrated.

Therefore, I am not moving-on, I am going to paint another base-layer.

Level one.

Family.

It is more than this.

It is survival.

Our instinct to wake in the morning and do something.

Our search for meaning or association with a more concrete or substantial essence; yes, that was obscure, but, how do you bring into words something that is lost in time, potentially there, before the development of language, of society.

As a species we all passed through this early level of being, in the womb and during our first days of clinging to mama.

It is inescapable and, it is where we return when everything else has fallen away, when we are standing naked, when we are faced with threats that are overwhelming – trauma, tragedy, violence, fear.

When the walls are falling-down you might consider calling the rescue services, but very quickly you realise that the thing to do is – run. Panic, reflexive responses to existential threat takes us out of ourselves, away from refinements of language and society; staggering from the ruins of a terrorist attack or lying helpless in hospital recovering from sepsis or surgery; it is us and the elements, us and our basic physiological and psychological ability to be that maintains us; our heart beats, we breathe, thermo-regulate. Nothing else matters.

This is the first tier.

This is stripping away the layers of culture, education and religious heritage.

Most of us do not return to this place except in our dreams and, whether that is good I don’t know. Perhaps if every person saw themselves for who they are, naked before god or evolution they might not spend so much time worrying about the transience of possession or achievement. Not to say that these things aren’t important, just, there is more than that. More than the big car, big house or five-star hotel.

Have a good day.

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Spiral (2)

I left Monday having started talking a little about the spiral with a specific foray into teal.

If anything I wrote bore even the slightest resemblance to the facts, it is that most readers will not have understood anything. That is, unless they already know all about it (Hi Claudius, Michelle and Jane!).

That wasn’t meant to sounds arrogant, just how I perceive the theory – if it makes sense, first time around something is wrong; OK. So, some of you might not have heard of this before and already have the theory stitched-up (despite my not having covered much; whatever).

Steve Jobs said, ‘simplicity is the ultimate sophistication’ – well, I guess if you follow that notion, the spiral is entirely unsophisticated, at least on first reading.

It isn’t for babies. It requires effort; work.

Let’s go back.

On Monday I also mentioned memes. Now, my 15 year old son is very familiar with these – they are big on the Internet; he showed me some of his and despite his mirth they made no sense whatsoever to me. I will try to track some down to show you. We also showed my brother – he was equally nonplussed.

Isn’t that the point? My son’s cultural heritage is in its very nature different to mine; his experiences, future and sense of what is funny are not the same as mine (It’s Always Sunny in Philadelphia?) (I eventually warmed to Parks and Recreation).

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We had a sense, my having discussed this with him, that my memes and his were different; in that the concept of meme was different – his to do with peculiar (to me) Internet graphics and mine with concepts of cultural evolution. Although I don’t totally have it, I suspect they are one and the same.

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To the spiral!

The spiral (which I suspect needn’t be a spiral, could be a Curly Wurly) begins with the start of human evolution – when we shifted to becoming what we are now; that is, Homo sapiens. The immediate family and its survival.

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This was the way we humans first organised.

There are not many places where this exists today; where people (organised groups) don’t just know one another, they are related either by genetics or pair bonding.

At this level of development or, evolution that was what worked at that time; what more was there? This family, battling to survive, reflecting instincts, fight or flight is the first level of the spiral.

Now, those folk living in families were the same as you and me; their memes would have been different, but, take a baby from then, send the tot to the 21st century and they too would be fretting over GCSE’s 15 years later. Little has changed in our biology in that time; we might be a little taller, have more heart disease or neuro-degeneration, these however relate predominantly to environmental and social changes rather than something in us. (Immunology and epigenetics have I guess evolved.)

My point; is, then and now we are the same, mostly.

Yet, our interpretation of the world has altered to such an extent that if we were to meet; those original folk and modern humans we would probably perceive two different species.

I am getting bogged-down in the minutiae of sociology and anthropology; I will leave that to Noah Harari – I’ll get back to the spiral.

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The spiral, or the first step, is the family grouping. There is a colour associated with this, but it really is secondary and also, what this level is called isn’t all that important.

What matters is that we started somewhere; what we had met the challenges we faced.

If you reflect this across to Maslow, this is the very bottom of his pyramid – achieving the primary requirements of food and shelter. Once these are in place you can start getting-on. If not, you don’t survive.

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Now, this being the first-step, doesn’t mean that it is a worse step; a naughty-step of civilisation, just one which was best adapted to that time and place; just as a butterfly is best adapted to getting at the nectar or an eagle perching on its eerie.

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There is no good or bad, better or worse; just different. This is the birth of diversity.

I promise to get to the colours and all the rest eventually, but, for now, let us suffice with this first tentative step.

It really is so removed from today – my sitting watching the sun set over the Mediterranean, laptop and internet; the mess/miasma of modernity that it is hard to conceive, yet, just as with the traditional evolution, it is a phase all of us pass-through; our early family life, dependence on parents, siblings or close family.

An aside, which might help emphasise the point, you can find in studies of embryology.

This is the time a fetus is sitting warm inside the womb.

As the embryo grows and differentiates it passes through a fish-like phase where we have gills, just like a fish.

Here is a picture.

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This doesn’t mean that we all have fish within us, or, as with above, tuna aren’t as sophisticated as humans, just that there is a link buried within that is mostly not noticed. (Douglas Adams has this sussed).

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Again, this is probably side-tracking, and now, I think, probably the best way for me to explore the spiral is for individual blogs focusing on each.

Have I explained the first tier?

It seems to me straightforward.

The family unit;

Ma, Pa and baby bear, exposed to the elements.

The vicissitudes of survival.

Sure, some miss-out on this, the point I suspect relates to us, that is humans as a whole, as a species.

Again, all this seems quite removed from my usual concerns of older people waiting in line for a blood test or a visit from home care A, B or C.

Yet, it is directly linked – our need for family, our dependence on one another, the sense of loss when a parent dies or the sandwich generation rushing-in to care.

Families are part of us no matter how much we pretend this is not the case; for the good and the bad.

Our helplessness as babies or dread of separation and loss.

Our family helps with our identity, it is a link to the past and a mirror on ourselves. Busy at important job in the city or rushing around the hospital ward, anxious over unemployment, our families are within us. They don’t go away no matter how much we pretend. And when the family is gone, passed on or moved-away, the memories play-out either in our dreams or our imaginings. Part of us is part of something else, our genetic linkage, or childhood memories or reflections in the mirror.

Family is where you begin.

It is where the group starts.

It is a route into the dynamics of a team – how we relate, how we connect and associate with one another; archetypes of our parents, our brothers and sisters, transforming into work colleagues, teachers and mentors. A reflection through time and space.

Again I have spilled-over the word-count.

I’ll try to do better the next time.

For now, I will leave you with a teaser; I will reveal the colour that is family or tribe, remembering that it is arbitrary;

It is beige.

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Spiral

I have been teetering on the brink of discussing this for years; I thought now was the time.

The problem with what I am about to write is, I have quite a low level of confidence in my ability to adequately do justice in a blog, explaining ‘the spiral’ and what it is about.

I won’t know until I begin, so here it is.

Oh. And before I start, I’ll say that this will be more than one blog’s length; this will be an introduction.

Forgive the preamble.

The story began around five years ago when I first me a group of people who were, let’s say, on my wavelength*. They were talking about, in particular something called teal.

Now, I had no idea what they meant, although from the way they described it, the whole thing sounded interesting. This was in the days before I had an idea what teal was (even from a colour perspective). Originally I thought it perhaps the name of a concept – which it was, and also assuming it had some sort of deeper meaning – which is does and it doesn’t.

You see why I have struggled with this?

I’ll go to the teal and work from there (bearing in mind that there is still lots of this that I have yet to understand).

Much of this came from a book written by the Belgian business-thinker Frederick Laloux.

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In 2014 he published ‘Reinventing Organisations’ in which he described different organisations or ways of working, collaborating, structuring the collective, which he based on the theory of the Spiral.

See? I haven’t even started and I have tied-myself in knots!

Well, the theory he used was that of Spiral Dynamics.

Spiral Dynamics – originally described by the American Psychology Professor Clare W. Graves in the 1950’s and 60’s and which he called – ‘The Emergent, Cyclical, Double-Helix Model of Adult BioPsychoSocial Systems Development’ was his first attempt to articulate the way that different societies (teams, groups, companies, collectives) function across the world and over time.

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I will not give you a description of this now (you’ll have to wait), let’s say that Clare conducted research in an attempt to understand why people behave in certain ways and consequently what makes groups, teams or collectives function differently.

All this at the time was couched in highfalutin academic language.

In the 70’s Graves met Don Beck, a Texan Psychology Professor who joined him and together they translated what was obscure academia into a slightly more straightforward concept, which over time – and, in particular the involvement of the South African Anti-Apartheid movement (you weren’t expecting that were you!), developed into the more straightforward Spiral with its associated colours.

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I am going to skip the Graves and early Beck work and focus on the colours;

Are you intrigued yet?

Are you still reading?

Well, Beck and Graves, identifying that just as evolution affects all living organisms (presupposing you believe in evolution), physically, the concept here is that humans over millennia, i.e. throughout our history, have been influenced by cultural evolution.

This began back in the day when we were in small family groups, subsisting, hunting, beating-up Neanderthals and enjoying the bounty of Planet Earth before motorways and high-rise buildings.

This was the first tier – level of the spiral; our beginning point you might call it – before this we were probably less organised, maybe like bonobos or some other clever primate.

And so, with increasing sophistication, learning, passing on of cultural traits and information, which are called Memes (different although the same as the inane jpeg’s that are shared on social media), society developed, through stages of increasing sophistication.

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After this first level people organised into entities, where you weren’t necessarily directly related to everyone in your group; this might be a tribe;

To save my typing, here is a picture:

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Using this model – or theory, society has advanced over time through different phases which brings us to the most up to date concepts of shared-decision making, co-creation, collaboration both in teams and across nations, the latter facilitated by social media (when not being used to share cheeky-baby memes).

If anyone who hasn’t heard about this concept before is still with me this far into the writing, congratulations – you are doing better than me!

In my case I had to read and re-read much of the ideas described before they sank-in in any meaningful way.

Now, they kind of make sense in most situations.

I am going to pause here and flip back to teal.

As I said, I met a group of amazing people a few years ago who also seemed both interested in the concepts that matched the name ‘teal’ and, were keen to involve themselves in different ways of working. When I say different all I mean is what I described above – co-creation, collaboration, compassion, caring and shared decision-making. Nothing too outrageous, but, when you translate this to were most of us were at the time, inured in 2010’s British health and social care things start to make more sense.

The past ten years has seen the biggest changes both for the good and the bad in health and social care (as I usually prefer, I’ll call this ‘Care’) – all the way from human genome project, face transplants, over-the-counter Viagra, genomics and gene therapy to long-length of stay, delayed discharges and workforce crises.

The good and the bad you might call it.

Just as with our ancestors lounging around East Africa, society reflected the times and, people operated with the times; East Africa – small family groups into related tribes and in Care, mostly, command and control, top-down, hierarchy.

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Now, it might sound and anyone who has read my blogs probably has the idea that I am not that keen on the modern style of leadership; well, yes. Although it has done very well and served society in ways that are beyond what anyone might have imagined when the first pin was created at one of Adam Smith’s factories in The Wealth of Nations, it has taken us from there, through industrialisation to our current state of environmental near-collapse.

And from this, well, it’s not really a mess, more a chaos; the one that says, wear a suit or uniform, turn-up at 8 and clock-off at five, book your leave a year in advance, obey these policies and procedures; we, as a society are trying to find different ways of moving-on;

Another example, is the dominant system (and, I am talking, global here) of democratic politics, where Right-Wing seem to have understood how to garner votes and everyone else is scrabbling around ineffectively speaking words that don’t translate into action.

This is using the same system of control that helped get society to where it is, but can’t take it any further.

As demonstrated by the UK’s Brexit-balagan.

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Already I have written more than I like in a blog and I haven’t even started explaining in any detail the spiral, what it represents and what it is about;

I have thrown-in some names and words which, if you are familiar with this stuff, might be reassuring – Laloux, teal, evolution, and, if this is your first time will likely just sound like mumbo-jumbo.

I am going to pause here and continue this – I promise; soon.

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*Angela, Jane and Helen were the main protagonists.

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Overthink (2)

Scraggy, wet feathers

I’ll try not to mislead any of you this morning – I am calling this Overthink part 2 as yesterday I had planned to write about this but lost my way.

It is wet again.

Going back to last week’s conference and Professor Ian James from the UoBradford, another comment he made which I thought quite profound, related to thinking and dementia.

Those of you who have read previous blogs on the subject might have encountered my attempt at Latin; yes, I am no Latin scholar, but the dictionary helps. Dementia – which is derived from ‘out of one’s mind’ is not necessarily useful, particularly when we are trying to understand another’s experiences.

Indeed, the only people I know who I suspect are out of their minds are Brexiteers and Capitalists.

Sorry.

No, the professor’s point related to the thought processes of people living with dementia.

If, say, I am taken in my sleep to location X – might be a hospital, could be a detention camp, and, eventually I wake-up, it probably will not take me long to work out where I am and start planning what to do. (Depending on the movie this could be longer or shorter).

This process requires complex brain pathways and interactions whereby I determine i) This isn’t my bed ii) I don’t know where I am iii) Those bars on the window are unfamiliar iv) The people on the other side are watching me.

From there I will hopefully work-out what to do, even if the only thing I can do is wait for something to happen.

This all requires a healthy brain. One which has a short and long-term recall function, an ability to process, to convey messages to and from my emotion centre, involving my frontal lobes – all in a kind of magical way that no-one yet fully understands (if ever viz. Pascal).

For someone who has dementia and, as previously described, there isn’t ‘dementia’ but infinite individual variations based upon the person’s life history, experience, physiology and, well, pathology.

The function of getting to a point where I can accept that nothing is happening and no one is coming to help me, at least for the moment, is disrupted and then begins the overthink.

If your short-term memory is impaired; to orientate, you might repetitively be asking yourself, ‘Where am I?’ or, ‘How did I get here?’ ‘What is next?’ – endless permutations that I perceive are like being in free-fall.

I can sit and watch the TV and enjoy the programme; at the end I know where I am and what is next; in dementia this can be disrupted. I might enjoy the programme, yet, as it comes to an end, so too does the process of self-orientation.

Add to this, perhaps, sitting in a care home with 40 other strangers around you, poor lighting, regimented meal times and difficult to navigate corridors and walk-ways and you can imagine why the whole thing might become exhausting and terrifying.

This I perceive is the overthink.

Imagine having to constantly re-orientate yourself to where you are and what is happening, if not, again, the free-fall.

How can we support people in this situation?

Well, the first step might be to understand that this is a possibility, that the person sitting or standing before you might be perceiving the world very differently to you and, because of a disease process, this is potentially less effective and efficient than it might otherwise be – this must be exhausting – imagine trying to travel at speed in first-gear; wheels spin and your engine overheats.

Beyond understanding are the usual tropes.

Give time and space;

Be kind

Smile

Empathise

Tolerate

Listen

Hear

Imagine yourself to be in their position.

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Overthink

duckling feet – pattering on the wet concrete

This morning’s walk was curtailed by the weather; I thought I would use the down-time to document something I heard last week.

I was at a meeting of the Yorkshire & Humber Strategic Clinical Network (YHSCN) for Older People’s Mental Health and Dementia (OPMH&D).*

One of the speakers, Professor Ian James from the University of Bradford was talking about a contentious area of health and care, particularly in relation to dementia, namely, ‘Behaviours that Challenge.’

This area is difficult, partially, as no one has as yet agreed on a name for the situation,  (behaviours that challenge, challenging behaviour, behaviour and psychological symptoms, distress…) also because it is equally unclear who has the problem or if there is a problem (or disease state) at all.

I’ll explain.

As with all the other over-wordy words of medicine, this has an abbreviation – BtC. I’ll use that, although somehow, reducing it to three letters makes things more difficult.

What are BtC?

Well, classically this is ascribed to situations where a person who has dementia interacts with the outside world in ways that are at odds with the desires or expectations of others. There are all sorts of BtC – someone who won’t sit-down when they are at high risk of falling, another person who won’t or can’t sleep at night, taking your pants off and peeing in the corner, shouting-out for mum.

All of these ‘behaviours’ to me have a common denominator – distress, and, it is this that links us to whether these are a condition or a natural response to difficult situations.

To explain more; If I imagine that I am in a room and I can’t find a way-out and I need the loo and cannot communicate this to the other people, either because I am fearful, too shy or simply unable and, I really need to go, I might go in the corner.

Is this reasonable adaptation to an impossible situation or a symptom of disease?

You decide.

What has become apparent is that in families and in particular care homes that are for whatever reason dysfunctional – that is, aren’t harmonious in some ill-defined way; for example, the leadership of the home is poor, there is significant staff stress and absence, or, the husband or wife have their own mental or physical health problems and are exhausted, struggling to support their spouse who has dementia – it is in these situations where BtC become more prevalent.

I have seen this myself countless times, when I have been called to see a patient who is described as either being aggressive, violent or unmanageable. Usually the intention is that I sedate. Yet, when I approach, using whatever means is necessary – sometimes slowly, hesitantly, at other times in a confident, ‘I’m the doctor’ manner, I rarely encounter the same response.

Nora 98, violent and aggressive becomes, Nora 98, who wants to hold my hand.

George 76, outbursts of uncontrollable behaviour, becomes, George 76, into trains.

Do you see the point?

Who is it who has the problem?

Are the behaviours challenging or are people challenged? Challenged to think beyond standard clinical models of patient and nurse, or to think outside of the medical box?

In the past BtC were frequently addressed by medication – often antipsychotics which worked by knocking people out (probably making them more fearful) and at times, killing them.

Now we are learning that language, behaviour, how we behave and relate to people living with dementia is probably more important than the medicine; care, compassion, empathy, time and understanding are often what is needed.

In care homes where staff have been supported and in particular, trained in understanding people, receiving lessons in person-centred care, the high levels of BtC disappear. No need for medicine, just some one-to-on teaching time – something that is rarely provided as standard for the carers working either out in the community or in care homes.

I realise it have come to the end of this blog and I haven’t even explained the title – overthink. I am afraid, this will have to wait until the next time, although I promise you it is fascinating.

Have a good day.

*Expertly organised by Colin, Penny and Carole.

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Doctor, doctor, can’t you see?

I remember several years ago a brief exchange I had with a friend; it was just before the elections where David Cameron was sort of elected (the one where he and Clegg manoeuvred/manipulated their way to power).

My statement had been something along the lines of, ‘Vote for Ed or it will be a disaster for the NHS.’

Well, the rest is history and that brings us to yesterday.

There was lots of media focus on an article from the medical magazine Pulse relating to the – if not collapse, the significant transformation of primary care – that is, for most of us, our local GP practices.

In the past year there have been 138 closures of practices versus 18 in 2013.

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Some of the stories described the experiences of doctors struggling to keep going yet failing with the eventual collapse and closure, resulting in untold suffering for the doctors – many of whom experience this as a personal failure and for the patients who experience the loss of a deep patient-doctor relationship they may have maintained their whole lives (and in the cases of practices that are ‘in-the-family’ this could be across generations).

“If I gave up, I think the practice would close because we’ve been trying to recruit doctors for months and nobody’s coming forward. It’s too stressful and the workload is too high,” she said. “We’re doing the work of five or six partners between three of us. Why would anyone come into this mess?”

Excerpt from the Guardian, 31 May 2019

Most of the collapse has resulted in changes first to doctor working patterns – more and more people are, when completing their GP training, opting to either not work full-time or to not join as partners (and with it the responsibility for maintaining the health and wellbeing of the little organisation you call-up when you have a funny rash, notice a lump or are too depressed to go to work).

With this change – the reasons for which are complicated; some to do with the shifting nature of society – moving from Baby Boomers to Generation X, Y and Z and the extension of working life (aka delay in retirement), to the realisation that for some, life is more than being a doctor; doctoring has to some extent drifted from being a vocation to that of an occupation, although clearly there is great variation in how people relate to this.

Perhaps a bigger challenge relates to GPs and often doctors in any branch of medicine (and, I imagine many other well-paid occupations) retiring, sometimes as early as possible.

I have never expected to retire – indeed, from my perspective, I have worked quite hard to craft a situation where I don’t need or want to retire.

The Baby Boom generation who are retiring now – those in their late 50’s and 60’s in the UK at least, if professionals, benefitted from free university education, grants and dramatic increases in house values over the 80’s and 90’s.

Their retirement age seems to be elastic and with this, again a variation, with some people I know opting to work and not stop when the pension arrives.

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I appreciate all of this is in the face of a society that is more unequal than at any time, with whole populations living with poverty; this is the milieu.

The reason for my meander into sociology was to explain that much of the reason for the collapse of General Practice is doctors who are physically and mentally able to work, opting to retire.

Work conditions over the past 10 years in the NHS have deteriorated beyond most peoples’ worst imaginings – the A&E trolley waits, nurse, therapy, pharmacy and doctor vacancies or even the recent reduction in life-span in our country are some of the indicators of a problem;

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Add to this the introduction a six or seven years ago of Revalidation which every doctor must undergo every five years – now spread to nurses and other care professionals, being a hurdle that acts as a disincentive to carry-on; and, the annual appraisals that although often tick-box in nature are a further burden (I’m not saying appraisal is bad, just, that I wish there was some way of automating the data collection rather than it being an additional burden to tired souls).

The net result of this as well as pressures from taxation (that I do not understand) have led to record numbers of GPs retiring.

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The response to some of this has been an attempt to redesign Primary Care – increasing the autonomy of nurses and therapists to see and treat patients without medical intervention; a move away from medical paternalism, which I love, and even Public Health shifts to get people to stop smoking and drink less (the latter of which is less successful as far as I can tell from the data).

Another change has been the development of super-practices that have joined together with 10, 15 or 20 different doctors working alongside nurses, therapists and other members of the team; receptionist, clerks, social prescribers, phlebotomists and so on.

When I was a kid there were two GPs in the practice, a couple of nurses and the odd receptionist, all out of the front room of one a doctor’s house (on Eastwood Mains Road).

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Sure, that wasn’t perfect and I suspect the health outcomes were not amazing either, but at least, when you made an appointment or sat and waited, you got to see the same Dr Kerr who knew your mum, dad, grand-dad; saw you the year before and the one before that; someone you didn’t have to relate your life-story to in order for them to know you, or, who didn’t need to skim through your electronic record to get a notion of your ‘problems’.

Those days have gone and, although I miss the toys (my brother used to borrow the odd edition of Time Magazine), the energy and efficiency of modern healthcare is far superior; except for the little thing about continuity.

And this is really the focus for this blog.

It is what is being lost because of all these changes.

Continuity in care, which, in other words means, relationships – human, one person connecting and getting to know another is a fundamental of all health and social care.

Beyond this we could frequently lapse into a form of algorithm; symptom – diagnosis – treatment.

This is fine for straightforward conditions – my favourite ‘UTI’ being an example, but what happens when ‘UTI’ isn’t UTI or, the high blood pressure doesn’t fit with the algorithm because the patient doesn’t want or can’t take or refuses to reveal that they won’t take the medicine, the secret stashers, who order medicines to ensure the doctor thinks they are taking them, but stashes bottles of Ramipril and Amlodipine in the cupboard.

What happens when the raised blood pressure is a sign of something else – dodgy hormones or domestic abuse? Will artificial intelligence be able to cope? I am sure one day the computers will be adequately sophisticated to see through this, but, when we get there, there is the likelihood of such a degradation of human relationship that society will have completely changed.

So, my stance is that humans are best at delivering care – the health and social variety; the meeting of minds, smile, humour, irony and associated emotions all contribute to something special that affects both clinicians and their patients, or in the case of social care, clients, very deeply.

And this can’t be replaced by algorithms and it is damaged if not lost by small GP practices becoming mini-hospitals, where you see a different person every time you are poorly and the computer rather than the human heart is the repository of your relationships.

It is this continuity that is being lost.

It has already more or less vanished from hospitals – changes to working conditions, shifts, rotas, working-time directives have created a workforce that clings to something called ‘handover’ which is the best we have to replace continuity, but which lacks any human bond – this is most commonly experienced by a nurse saying, ‘Sorry, I don’t know Sadie/George/Francis/Mum/Dad as I am just back from 10 days off; I’ll look in the notes.’

This is a frustration shared by countless patients and relatives;

How we regain continuity of care in hospitals is for another day; how we stop it being lost in General Practice is my focus.

Part of my recent shift to work outside of hospitals has been heralded by this situation – the process of hospitalisation not offering me the depth of connection I needed to maintain my passion for care and the realisation that I could do more to maintain this out in the community.

Already I am developing relationships.

I am getting to know patients by their first-names; hearing about their work, their families, the husband who died young or the sister with cancer – the grandson who is at university and the family dog.

All of these add richness to relationship and whilst not essential for me prescribing penicillin are essential to my humanity.

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The trouble with keeping people well.

We have a health and social care system that is built upon failure, or, at least, things going wrong.

Let me explain.

Imagine I invented a medicine that kept people well.

It is a pill you take, and it prevents disease.

Clearly, this is absurd, as there is no such thing as disease, only diseases (like when we think of a cure for cancer or dementia – these are multitudes of different conditions, not like say, a vaccine for measles which is one pathogen.)

In the trade they have a term for this, ‘Snake Oil’

I remember John Diamond writing about it years ago.

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We have a branch of medicine called ‘primary prevention’ – this is the treatment of states that aren’t quite diseases but, if left unchecked can go wrong. The most common example is the monitoring and treatment of raised blood pressure.

High blood pressure (so long as it’s not too high) isn’t that awful.

We use millimetres of mercury to describe this physiological state.

Normal is 120/70 – higher than that at you approach hypertension; lower and you are hypotensive. You see, anything but normality has a name (even when normal you are normo-tensive).

Having a blood pressure of say, 150/80 is not in itself particularly harmful, it is the effect on your whole-body system over a period of time – years, sometimes decades that unleashes a multitude of different, let’s call them pathological processes – heart, kidney, brain disease.

We prescribed anti-hypertensives to achieve as low as possible a blood pressure without it becoming too-low – which carries a risk to health and wellbeing, not just of falling over, but of premature death.

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As we learn more about health and disease we discover other similar states – for example, when I was a student, folk used to be diabetic or not; now, people fall into a state of pre-diabetes, which with appropriate attention – often lifestyle changes, we can avoid progression to the inevitable.

And, these are just two conditions.

There is measurement of cholesterol, lung and cardiac function, psychological health and wellbeing, skin, eye, teeth and auditory health.

A lot goes in to ensuring that we stay well.

And, none of this has a straightforward solution.

There is the adage, ‘All things in moderation,’ but that doesn’t necessarily prevent you from developing cancer or raised blood pressure if you are genetically predisposed, no matter the cups of tea you imbibe.

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Perhaps this explains why prevention is so much harder than either treatment or cure.

In a previous blog I wrote about the pyramid of risk; where, given limited resources we direct our actions to those most likely to benefit, generally, this is those most at risk, the old man who has fallen rather than the man who might fall; the woman who has had a heart attack rather than her sister who is otherwise well.

There is a whole science behind population screening – this is where you take everyone of a certain age and/or gender and provide them with a screening test; for example, cervical screening, mammography and aortic aneurysm screening programmes to name a few.

For these, much time and effort has been invested in determining whether screening is the right thing to do and adequate numbers of lives are saved versus the cost, the inconvenience and associated anxiety cause by subjecting hundreds of thousands of otherwise well people to medicalisation.

One day you change from being ‘Rod’ the person into ‘Rod’ who has a 5cm aortic aneurysm; your whole life flips and with it your approach to wellbeing, mortality and, potentially relationships with insurance companies.

This is one of the risks of trying to keep people well.

In China, back in the day before Hong Kong and the opening of their markets, when people used to cycle around and practice Tai Chi in the park before work, these cultural aspects led to health and wellbeing – physical and psychological; I think the Dutch have managed to cling-on to the bikes.

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What happens when you start mandating or prescribing bikes or long walks?

Another innovation we have in the UK is Social Prescribing; this is where your doctor or nurse identifies that what is wrong with you isn’t something that necessarily requires a pill or a procedure, but activity or, other people.

You prescribe a session at the gym, a social club, a walk in the woods with others of similar ability. These are alternative approaches to loneliness and social isolation.

This so far has proven very popular and is being rolled-out nationally; it was even included in the recent NHS Long Term Plan – the government’s attempt to point care in the right direction; as to whether it is the right or best answer we will discover. Most people, when they have a bad back want a pain-killer and to get back to work, not a kindly doctor telling them to join Weight-Watchers.

Again, something I wrote recently was my reluctance to wait for evidence-based medicine to determine what I should do. The academics will tell you that without this, (otherwise known as ‘EBM’) I risk doing more harm than good; my one-to-one conversations with all the residents in the care home, rather than creating a situation of trust and confidence, leads to dependence and increased anxiety.

I guess the point here is to tread with caution – to approach each clinical encounter with the sensitivity that whatever you do or say could be taken the wrong way; your attempt at reassurance could lead to worry, by stopping the supposed dodgy drug you have led to unanticipated complications or side-effects.

The point of this blog is probably to suggest that we shouldn’t be so hard on either one another or on the system.

Very few people are out there with the explicit intention of doing harm;

Sure, British American Tobacco are still going strong and the Petrochemical Industry is exploiting the planet, but most of us, particularly at the level of the individual are just trying to get by, looking-out for family and friends and then, when you are confident they are safe, community and society.

You don’t need to accept things for the way they are, you can work towards change and growth; you are more likely to achieve your goals through a humanistic, love and be loved approach rather than one steeped in cynicism.

Thank you.

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Korzybski, Beck and sorry, I don’t follow.

I am listening to Don Beck’s ‘Spiral Dynamics Integral’ on the Audible.

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This is Don, the Texan professor of psychology and, let’s call it, the evolution of human development talking about his theories and those of his mentor, Clare W. Graves.

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I won’t expand here as a) it is all very complicated and I don’t quite understand and, b) I haven’t finished the book; I like to approach books the way we should regard humans if we are to avoid the Saville trap; that is the hazard of praising something before we know enough about the good and bad.

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Yes, I am digressing.

In the most recent chapter Don covered (superficially I suspect), the work of Alfred Korzybski, the Polish-American academic who worked on Semantics – that is, the meaning, purpose, utility and essence of words and language; (his most famous quote being, ‘the map is not the territory’).

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Taking a specific he raised (AK), and relating it to my world of medicine brings us to the clinical consultation.

The most basic set-up is patient and doctor; you could of course have patient and any other variety of clinician, but given that I am one, I will stick with the former; and, it isn’t always just the patient – there is often the husband or wife, son or daughter.

The greater the number of people present the greater the complexity and the higher the risk of falling into what I have decided to call the ‘Korzybski Trap’

This relates to the different meaning or conceptions people have for words.

That wasn’t a particularly elegant sentence; I couldn’t think of a better way to phrase it – my point, and I think one of AK’s was that when you say a word, for example, ‘blood’ this will result in a certain set of associations and ideas. Specific neural networks will fire that will inevitably be different from anyone else (I am me after all), and, the extent of the variation will relate to my world view – based upon my experiences, knowledge, preferences.

Therefore, ‘blood’ to a doctor – a general bod like me has specific associations, such as:

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The red stuff

Haemoglobin

Oxygen transport

Anaemia

Iron

You get the idea, yet, to someone else, the representation might either be narrower or just different:

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Infection

Contamination

Wine

Stigmata

Cut

And again, for someone who has more specific knowledge, say, a haematologist:

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Haematocrit

Poikilocytes

Thalassaemia

Von Willebrand

Philadelphia

 

You get the idea.

Now, society is based upon the idea that although we are using a common language and despite our different interpretations we can muddle-though; we have passed beyond the Tower of Babel, yet, what happens when the patient leaves the room? What do they understand from the phrases the doctor has used?

My blood is too thin

My blood count has dropped

I have too much blood

My blood is bad

The latter making me think of Taylor Swift, the recent book about dodgy Silicone Valley Tech and the Tuskegee Syphilis Study.

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It’s a wonder we get anywhere.

All along as I write this, I have had something niggling at the back of my mind and it harks back to the Heathcote Williams poem, ‘Mokusatsu’ which relates language to the dropping of the bombs on Hiroshima and Nagasaki.

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The point of all this?

Perhaps it is for us to pause.

To reflect, the next time you hear something, perhaps someone say a word or use a phrase that generates a response inside you, that there might be more going on that you have at first understood.

None of us can help the reflex, that cuts straight to the amygdala’s (almond) emotional response, yet, perhaps there is learning of what to do after these brain cells have fired, before we take our next step.

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First

In my life there have not been many occasions where I have come first.

Sure, I have done well sometimes, but rarely first.

First suggests sometimes the best. It can also allude to novelty – the first step on the moon comes to mind; it is hard to say whether that was the best step on to the moon, but, certainly, no one had ever done it before.

Here I am talking first in the Armstrong sense, rather than any kind of aspirational, ‘could do better’ as has so often been my experience.

I am writing this in the shadow of my recent blog about tigers and their traps. I thought I would try to be a little less abstruse for those who prefer a more concrete approach.

As you can see, I have not gotten-off to the best start.

I am also keen that this blog gets published by the British Geriatrics Society – as with the Q-Community I haven’t had any success so far, although for the Q, moaning seems to have proven a winning strategy. Thank you.

Anyway.

An abridged version of where I am for those of you who haven’t yet given-up with the introduction;

I am, to the best of my knowledge, the first physician in the UK who has taken his frustrations with secondary care not into management or leadership, but into the community.

Many will be familiar with the sub-specialism Community Geriatrics – this refers to a specialist (Geriatrician – doctor, nurse or therapist) working in the care of older people who is principally employed by a primary or secondary care trust (aka big NHS bureaucracy) who spends some or occasionally all their time supporting patients in the community – that is, not in acute hospital beds or clinics.

This has been a fantastic development over the past decade or so and helps maintain many frail, older people in the community, out of hospital.

This is part of my job, but, you see, I wanted more.

I have long realised that most older people are not in hospital or intermediate care facilities; they are out-there – in their own homes, living with children or getting-by in residential and nursing homes.

They are in the community, but not in the community in the sense of hospital specialists, rather, they are sitting at their kitchen table struggling with beans on toast, or negotiating the short distance between front and back room; sometimes making it up to the GP surgery for a check-up, often not.

To see me in hospital or even in the community when I am wearing the badge of ‘community geriatrician’ mostly, something has to go wrong.

The person has to fall, develop pneumonia, struggle to eat, break a bone; some trigger must happen that results either in an acute admission or their GP contacting secondary care and asking, ‘Come out and see xxx’

If you take the entire population of ‘older people’ (an ill-defined group, but you know who they/you are), using this approach we are only meeting the needs of a tiny proportion.

Maybe 10 per cent if we are lucky.

An element between primary and secondary care aka GP and hospital is the requirement for either a referral – ‘Please see’ or an admission. Without this the two groups (old folk who frequently have multiple long-term conditions, frailty, dementia, falls, weight loss) are managed in the community; mostly very well but GPs and their teams but without the focus that someone like me – who you might call a pseudo-specialist can provide.

It is hard as a GP to see patient 1, 18-year-old with acne, patient 2, 35-year-old with bad back, 3, 2-year-old with cough, four, 99-year-old with rash and finally, 28-year-old six-months pregnant. (Within the hour).

Having this breadth of knowledge, ability and experience is phenomenal, but, only in certain circumstances can anyone know lots about everything (the odd polymath excepted).

And what is my first?

Well, I am joining a GP practice as a partner and supporting the older people across that practice area.

So, I am not a GP, I can’t be a GP and I don’ think that is something I would be able to pull-off. (I did apply back in the day to become a GP but was unsuccessful – I guess, you could call me a failed GP with FRCP after my name).

Now, I can call-up a patient and either invite myself into their home or bring them to the surgery on the basis of their medical complexity and perhaps frequent admissions to hospital; I can address polypharmacy and one of the most pressing issues – the creation of Advance Care Plans; these being documents that function to provide the best for our most vulnerable patients, often, supporting them to stay-away and out of A&E departments and admission units.

All of this is a work in progress.

I think this step which I am taking is one which will help liberate others within health and social care to do things differently.

I have met so many doctors who wish they had taken a different course. For those who are young and enthusiastic enough, you can re-train and do something else; for those like me, who actually love what it is they do, but struggle with the context, this is an alternative.

Imagine, you want to work with children, but as a doctor can’t face becoming a paediatrician (exams, relocation, hospital rotations); this could be an alternative. I know many people who enjoy supporting, caring for and treating older people but have opted-out of hospital practice because the idea of organisational life is not what they want; that and the on-calls, and the processing – the obsession with flow, bed capacity, accountability, command and control.

I am not giving-up on hospitals; I just think they need to change, and perhaps this might help them in their transition – in particular, to becoming more person-centred; not just in how they treat their patients, but in the experience of outpatients, relatives, carers and staff.

Small is beautiful. Yet, how do we maintain small in this world of bigger and better? Of mergers and networks? GP practices are facing the biggest change, which some see as a threat in a generation; pressures of workforce and recruitment are driving some to shut, some to become bigger and bigger, with, the risk of the loss of the jewel in the crown of primary care – continuity.

The NHS Long Term Plan seeks to fix this.

I see it more as a cry for help.

This I am hoping to support.

So, I don’t know if I am the first;

Multiple Google searches and conversations with colleagues leave me to think I am, which if the case, cool;

If not, please give me a call; I would love to hear what you are doing, how you are doing.

Here is to the next ten-years of change and growth!

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I’ll end with a quick shout-out to some people who have helped keep me going through all of this – Annie, Maisie and the kids, Jane Pightling, Clare Gerada and George Briggs.

 

To stop, or not: that is the question.

Yesterday (Friday) I asked Twitter a question.

I am never sure whether that is a wise, but, when you are sitting in a room, office or clinic, alone, and a you can’t find the answer to a clinical scenario it seems reasonable.

The question I asked of colleagues was whether there was a way to help prevent older people, many of whom are in the last years of their lives from being taken to hospital when they fall.

Work relating to this is the focus of Advance Care Plans – something I have been thinking about for several years.

It seems that there are some scenarios that are more straightforward than others.

For example, if you have a person who is say, in their late 80’s, living in a care home with advanced dementia, to the point where they are unable to conduct a meaningful conversation, require assistance with washing, dressing and eating and also have the usual host of associated conditions that people pick-up with a lifetime of getting-on, say, diabetes, heart disease and, atrial fibrillation just to begin, this being frequently the ‘average’ care home resident; I’ll even give them a name; Sadie*.

Working on a plan, which is ideally drawn-up with Sadie before she becomes too unwell to be involved in the decision-making is ideal; yet, frequently this doesn’t take place and the discussions happen with sons and daughters, husbands and wives, often after a series of disastrous attendances at A&E or admissions to the hospital where Sadie traumatised and potentially damaged from each episode of x-ray, blood test, intravenous cannula, catheter, bed and ward moves and so on, reaches a point where Sadie’s son or daughter decides, ‘No more!’ and issues an ultimatum that the next time their mum becomes unwell she must not be taken to hospital.

The above is facilitated by the presence of an insightful GP or other community doctor who can fashion a document to support the statement, acknowledging the subtleties and complexities of the process.

What does, ‘No more!’ mean? Sadie falls and does her self no obvious harm, Sadie develops pneumonia and becomes drowsy, she vomits blood or struggles to breathe; she has pain in the abdomen, an apparent headache or itchy rash.

You see, the possibilities are endless. It is hard to predict every situation.

What if Sadie falls and breaks her arm? (After we have done everything humanly possible to minimise her risk of falling – address antipsychotics and sedative medicines, postural hypotension, foot-wear, spectacles and so on.)

Hospital transfer might not be ideal, but a little traction and a Plaster of Paris can significantly improve the pain; Sadie might not understand the purpose of the pot and pull it off, but at least you can try.

All of this is taking me to the question I posed.

It has to do with planning ahead and a small area of medicine and law that no one has as yet addressed.

Here is the scenario.

We will stick with Sadie.

Sadie has advanced dementia; in the past she has had a stroke and high blood pressure and now she has an erratic pulse – we call this atrial fibrillation.

The condition itself, where the atria of the heart ‘fibrillate’ that is, function in a chaotic, inefficient manner is not particularly harmful although it can make your overall heart function decline (leading to breathlessness, for example), it is however the association that is more sinister –

Because the chambers of the heart don’t contract normally, the blood flowing through them is disrupted and can collect leading to the development of a clot; if this clot breaks-off, it can cause a stroke, which is of course potentially devastating.

The best way we know to treat this condition is through the use of oral anticoagulants – Warfarin is the most well-known, although it can be tricky as it requires regular monitoring through blood tests – to make sure the dose achieves the sweet-spot of thinning the blood adequately to avoid clots but not too much to cause spontaneous bleeding.

A new class of drugs, originally called ‘novel anticoagulants’ (NOACs) and now, that they aren’t that new, ‘direct oral anticoagulants’ aka ‘DOACs’ have overwhelmed the marketplace; these pills don’t require the constant monitoring and in general are safe although there isn’t a ready agent to reverse their effect as with warfarin.

Because of the ease of taking – it is a set dose to be taken daily, and also, there is no need for blood tests, these tablets suit older people, especially those who struggle with the different daily doses that are sometimes required for warfarin to keep it in at the right level.

Remember however, despite their ease of use, they can’t be ‘reversed’ easily.

Anyway, it isn’t really the reversal that is the point, more, the guidance from the viziers of medicine in the UK, NICE, who advise that anyone taking an oral anticoagulant who experiences a fall and head injury should have a CT scan.

This guidance is completely reasonable.

Being on a blood thinning treatment increases your risk of bleeding and a knock on the head can cause internal bleeding which can initially be undetected physically but show-up on a scan which can then lead to treatment and in some situations, neurosurgery (the archaic burr hole).

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The complexity is, that if a person has significant or advanced dementia, not only can the transfer to hospital be traumatic, let alone the medics’ attempts to take blood and organise a scan for someone who is often frightened, anxious and lacking understanding of what is happening, invariably, even if there is some bleeding, there is no treatment other than stopping the medicine.

You might think, well, if that is the case, why take people to A&E in the first place; leave them on the medicine if it is benefiting them (for people who have atrial fibrillation and a previous stroke the benefits of anticoagulation are significant – something like a 60 per cent reduction in the risk of future stroke) and if they knock their head as there is nothing that can be done, leave them in the care home.

Into this mix is the defensive nature of care homes, all of which are very vulnerable to litigation and threats of foreclosure by the Care Quality Commission (CQC) and also criticism by the coroner if someone dies after falling and banging their head – which in most parts of the country is associated with a requirement to refer a death, even in someone you are expecting to die, to the coroner.

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Care homes, paramedics and doctors don’t want to fall foul of the CQC, or the coroner and the usual response is to take Sadie to hospital, even though everyone knows it is the wrong thing.

Do you see the conundrum?

The medicine can help keep Sadie ‘well’ and as independent as possible in the care home, able to achieve whatever quality of life is possible within the confines of her condition, yet it can also result in a harsh episode of ambulance conveyance which is ultimately futile.

Ironically, doctors could determine that it is no longer safe for Sadie to take the anticoagulant which would remove the risk of hospital transfer, this would however increase her risk of dying from a stroke.

No one I know has an answer to this.

Acting in a person’s best interests is the phrase we use when we can no longer apply the more valid, ‘What Matters to You’ – yet, frequently best interests come into conflict with legality and protocol.

You might wonder how I could squeeze this question into a tweet; well, this situation is so well-known to many people in healthcare that I could sum it up in one sentence and wait for answers.

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Unfortunately, no one has an answer and our patients, their relatives, the paramedics, care home and emergency department staff continue to exist in a limbo where doing what is right is increasingly more challenging.

I would like to hear what people think, particularly if you are a coroner or a high-court judge.

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*Sadie was the name of a much-loved great aunt who lived on Bellwood Street in Glasgow.

Purposeful Practice and an agreement to disagree

Yesterday I finished listening to ‘Peak: Secrets from the New Science of Expertise’ by Anders Ericsson and Robert Pool.

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The book explores the phenomenon of experts – those who manage to go further, see beyond, run, jump or swim faster; the top competitors in chess and Scrabble, the Magi of art, music, physics and literature.

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You see, the writers suggest there is a common theme which has less to do with innate talent or IQ and more to do with what they describe as Purposeful Practice – a form of mindful self-improvement and growth; where an individual participates in whatever art, science or sport, repeatedly, but not just blindly doing the same thing over and over, more, learning from each action, each practice to find new ways to go beyond;

All of this is helped by having a good teacher, as they can act as a guide in how to make initial progress, or a coach, who can provide an objective assessment of your performance and propose alternatives.

Mindless Practice, just like Mindless Medicine, for example, where people carry-out tasks with their bodies but their spirits and focus are elsewhere doesn’t do anyone any good – in healthcare this results in mistakes and errors, in other branches of life, people eventually stop practicing as they make no progress.

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Another theme of the book is that anyone can achieve mastery or excellence in a skill or ability (with some specific limitations relating to height and body size – no matter how much you practice, if you are too tall or too small you won’t make a great Judoka or long-jumper).

In the book they even dispel the myth of savants – those who have specific abilities that appear transcendent; the old men who can tell you which day of the week the 24th of January 8031 will fall, within seconds, or the wunderkinds who can draw in detail representations of a scene they have observed once for five seconds seconds.

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The writers suggest that what makes these savants able to perform in this way is not magic, but the adoption of strategies of purposeful practice;

Even, it has been found that chess Grand Masters, who we mostly tend to assume to be people of great ability if not genius, frequently have below average IQ’s.

I won’t go into the detail; you had better read or listen to the book if you are interested; I have a copy if someone wants to borrow one.

Where I am heading is the disagreement last night where I was discussing this with my son, or, rather, I believe we agreed to disagree, although I suspect we really agreed.

My son has his GCSE’s this week and into next month.

In some subjects he has a natural interest and enjoys learning, in others less so.

He believes that this is because he is good at say, English, and not good or lacking in ability at others, for example, Maths.

Over the years I have seen kids, peers of my children who are apparent whizzes at Maths. By the time they are 12 they have progressed to sitting the A-level. In the past they used to get on to TV – with headlines like: Six-year-old tot with five A-levels; considers Cambridge.

The assumption being that the tot has some abilities that put him or her beyond, in a different space, one which only those fortunate to be born with the requisite genetics can obtain.

 

The book says and the science suggests this isn’t true; the tot is just a tot like any other, it is just that for whatever reason the child has either been exposed to, forced to comply or just enjoys doing maths or chemistry or whatever from an early age.

Anyone could do the same.

A good example is Mozart; everyone assumes he had a God-given gift; so, thought Salieri in the movie.

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No, again, it is practice.

You can find children brought-up with the Suzuki Method able to perform the violin or piano just as well as Amadeus likely could at the same age.

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I appreciate I am not doing very well creating a narrative in this blog; the reader is possibly wondering, what about your son?

Well, my mission was to convince him that he is neither better or lesser than those other kids who seem to be naturals at Maths – it is just that the ones who are very good dedicate far more time to practice and in particular Purposeful Practice.

My kids never really liked My Maths – the go-to for maths teaching in the UK; the children who saw this as fun, as a game, as a way to curry favour with parents and teachers, who instead of watching Power Rangers sat at a PC for hours and practiced are the ones steaming ahead.

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I think we agreed – once we had faced the issue as to whether I was actually insulting him (you are just like everyone else), teaching him humility (ibid), or, bigging him up (you have worked harder than lots of other people).

For now, I want to return to the democratising concept of equality.

Races, genders, ages, we are all equal and all have equal abilities; we don’t all have the same opportunities; that is for another day;

Imagine, if, with the ongoing expansion of the life on Planet Earth, we were able to harness some aspects of this training to grow the number of experts; imagine the new normal would be that when you see a doctor, the expectation isn’t that they are as good as everyone else (the Bolam Principle), but, that they are as good as the best people in the world; it just takes the right training.

If we facilitate exposure to training and education to a greater number of people, and specifically, the right education – not just parrot fashion rote, but deep understanding, learning and growth, we are likely to achieve a better understanding of the world and hope for tomorrow.

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I’ll leave with an anecdote about Richard Feynman – a physicist considered amongst the greatest minds of his generation (also a crazy bongo-player, linguist and lock-picker) – Feynman (one of Sheldon’s heroes on The Big Bang) apparently had an IQ of 126; this puts him in the bracket of very clever, but not a candidate for Mensa or genius level which is traditionally considered to be an IQ of 140 or more.

Yet he was a genius.

What is genius?

It is no big deal according to the writers;

Please have a good weekend.

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Tigers, long-term conditions & my new life

When I was young, before it was known that tigers and many of the wonders of nature were on the verge of extinction, there was a thing people used to talk about and which would occasionally enter my dreams.

Tiger traps.

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There is probably an old film out there where this features.

You take a well-trodden path in the jungle, dig a deep hole (not forgetting the ladder so you can climb-out), cover the hole with leaves and wait.

Eventually an unsuspecting tiger wanders along and falls in.

Voila.

Looking back and knowing how big the tigers are, the hole would have to be very deep; there you go.

What is the link with long-term conditions?

You could add older people to this.

You see, it dawned on me a few years ago that there is something wrong with how hospitals function; this is not to say that they are all wrong – yesterday’s blog about the profound ability of surgeons I believe demonstrated that, no, it is how we match-up doctors, and patients with either long-term conditions or in my case, older people, and, particularly those who are very old, very frail and at significant risk of deterioration (most commonly translated into either a fall or an infection.)

It’s like the tiger.

The hospital is the trap, and the doctors are sitting and waiting.

This is not to say that there aren’t folk out there pursuing the tigers (these are GPs and community staff) – it is just that there are so many other distractions that it is hard to focus (the young, the pregnant, the lonely) and, what we know about hunting is that you require singular concentration (ideally, working in teams – that’s for another day).

In the hospitals (the hole) we sit and wait.

Eventually, inevitably, the older person will fall-in; literally and figuratively. Or, the person with diabetes will go wrong, the middle-age man’s asthma will deteriorate or the young woman who doesn’t know what else to do takes an overdose.

And then the doctors go to work; ward rounds, or more common nowadays, a medical assessment unit team will be on you, doing their best to sort.

In the case of younger people, and if there aren’t too many conditions happening at once (we call this multi-morbidity), the person is fixed – their insulin adjusted, steroids prescribed or offered the opportunity to talk with a mental health nurse and they are off.

For older people where there might just be one presenting condition, when this is combined with frailty, social isolation and relative poverty, the turnaround is more difficult.

You do the tests, start the medicines and call the social worker.

And wait.

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In medical circles there is a big debate about how you identify those most at risk of deterioration, or in the case of the NHS’s current mantra, the people who are ‘avoidable admissions’ – usually this is portrayed as a triangle (or pyramid), with the most vulnerable at the top (the tigers) and everyone else closer to the bottom (maybe the wood-pigeons, or some other animal that appears to be in abundance).

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If you go after the pigeons, you wear yourself too thinly – we call this public or population health, where the most we can often do is a few posters on bus shelters saying things like ‘mind your waistline’ or ‘count the units’ – most of which is ineffective as the paltry sums available to public health bodies are inevitably dwarfed by the industry’s ‘Cadbury’s Caramel’ delivered by a lascivious rabbit.

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And the opposite is also the case; the academics say, there is a lack of evidence, even, if you go after the folk at the top of the triangle/pyramid, of this making any significant (p<0.05) difference; you’ll be wasting your time as it is too difficult to predict who will specifically deteriorate.

Those who know me will recognise my ambivalence towards evidence and academia.

Sure, it has its place, but the arguments are usually two-directional, in as much as their being just as little evidence of effectiveness for us doing what we are already doing, it is just that tradition, or more likely habit keeps us going along the same paths (heuristics).

What has been my idea?

Well, it was to stop waiting for tigers to fall into traps and go after them in a different way.

Me, a so-called specialist, has stepped sideways and taken-on some of the behaviours of the people who see patients all the time – that is general practitioners; I have literally changed my stripes or spots (or whatever analogy works) and gone out to the practice where the (dying to say, ‘Wild Things’) patient are.

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Not waiting for the trap or the referral letter, the ward round on the assessment unit; instead working in primary care, getting down to the nitty-gritty, identifying who the vulnerable folk are and sorting their medicines, their falls, their plans for the future.

In case I haven’t expressed myself well enough, the latter is another fantastic example.

It relates to Advance Care Plans.

This is something that fascinates me and, if you like, you can Google ‘almondemotion advance care plan’ to find-out more – or listen to this webinar;

These are the documents that say a person will not benefit from a return to hospital as they are too frail, vulnerable or confused; therefore, do what you can to support the man/woman, often in their care home.

These documents are okay, yet by and large, we have to wait for the person to fall into the trap and the people writing these letters are often hospital staff who really know very little about the person and in particular their social or care environment back home. Hence, they are often ineffective.

For anyone interested, I am in the process of starting-up a South Yorkshire (and beyond) Advance Care Plan group. Let me know.

Sorry; I digress.

I, having taken-on the clothing, demeanour (I hope) and behaviours of a General Practitioner can now go and blend-in with the care home residents, talk with them, their relatives, the care managers and work out how best to support them and allow them to achieve what virtually everyone wants – staying well, out of hospital and living their lives free of medical intervention.

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Two and a half days a week I have moved away from waiting beside the trap, to going feral, in search of those I can help the most, where most of the patients are – not in hospital beds, but at home, in their front living rooms, sitting precariously on riser-recliners or maintained in rickety beds.

I am out, I am free, I am getting to where the action is.

Getting to make a difference to people before the worst has happened; not only do I get to meet people at home, in their own environments, free from the anxiety and stress of hospitalisation, I can sit and chat, breaking down the hierarchical boundaries that are inevitably associated with hospital life and meet people as people – as equals, perhaps doctor and patient, but certainly not hunter and hunted.

I hope this hasn’t been too obscure an introduction into my new life; I promise to write more, the next time, perhaps more succinct and without too many perambulations.

Here is to the week ahead!

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PS NK – I know this isn’t a tiger!

Insight and polite surgeons (P&Q’s)

Last night, I watched episode two of Surgeons: At the Edge of Life. This time on the iPlayer.*

There were two patients with rare and complex conditions undergoing surgery; one a woman with a growth destroying her face and the other an older woman with an equally rare condition affecting her spine and brain-stem.

Neuro and Maxillofacial surgeons were involved in the intricate operations which both took over ten hours, in the case of the woman with the brain-stem condition, she went back for a second even more obscure procedure in an attempt to remove some of the tumour the surgeon couldn’t get the first time around.

Like episode one it was fascinating.

What stood-out for me was the politeness of the surgeons. No matter the pressure or the urgency, requests began with please and often ended with thank you.

This is being polite.

Does it matter?

Of course!

Sure, were the operation performed by robots this wouldn’t be the case, but, fortunately it will be a long time before robots are even able to undertake the most rudimentary forms of surgery, such is the complexity, the unpredictability (robots operating on robots is something else) and the necessity for synchronised team work that means it isn’t just having one computer that can perform the surgery, but several that all must communicate simultaneously and seamlessly.

Computers are not my point.

I remember, back in 1998 working with a crazed Irish surgeon.

The last thing he considered were the feelings of his team; he was blunt, quick to temper and on more than one occasion, stabbed me with a needle whilst swearing as he fiddled with someone’s intestines.

This guy lacked insight.

He certainly made the three months I worked with him miserable.

There is a notion that sometimes it is OK to be rude or condescending, to shout or display behaviour that could be construed as bullying, ‘Given the circumstances,’ kind of thing.

I disagree.

Over the years I have seen a couple of respected colleagues who for the most portrayed an externality of calmness and kindness behave in absolutely terrible ways, often when speaking with nurses, and, sometimes secretaries.

Note, that for the doctors, I have never seen this between other medics.

You might say, ‘The situation was unprecedented, a one-off,’ I don’t accept that; for if it were just an extreme event, it wouldn’t matter who you were exploding to or at; patients, professors or visiting CQC dignitaries, all would all be fair-game.

No.

What I want to examine in this blog is the subject of insight as I believe it is core.

Insight is a complex human phenomenon, best I think summed-up by Robert Burns – ‘If we could see ourselves the way others see us.’

O wad some Power the giftie gie us

To see oursels as ithers see us!)

To A Louse, On Seeing One on a Lady’s Bonnet at Church.

Do you need to have insight to be an effective doctor, nurse or pharmacist?

Certainly, those lacking this seem to struggle.

They often go around upsetting and offending, appearing mean and unfeeling.

Now, I know that the majority of these folk are good people (gutte neshumas) – healthcare does attract the odd psychopath, but not as a rule; it is that they don’t perceive the effect of their words or actions on other people, and, in the rare situations where this is brought to the fore, it can be very upsetting, even devastating–

‘Did you realise that every time you walk in the room all the staff are on alert, waiting for you to criticise, pick-on or otherwise attack them?’

Insight is a big area and the specific I wanted to consider here; is it essential? In other words, can you have a fantastic surgeon who lacks insight? Who has the most incredible technical ability, their hand steady, mental representations of obscure anatomy second to none, or, is this such an impediment that nothing good will ever come of their actions?

I don’t know –

If it was me with the tumour, would I rather have a highly skilled technical doctor who lacks all insight into interpersonal behaviour or one who hasn’t the requisite skill but is a sensitive soul, considering the emotions of those around them?

My usual trope is that I’d try to find someone who was adequate in both areas, at the very least.

It isn’t easy being a good nurse or therapist.

It takes intelligence, sensitivity and skill.

And often, lots of practice (which means, sometimes getting it wrong, learning, adapting and improving – a component of life which requires insight.)

Should we test or screen for insight at university?

‘I’m sorry you can’t become a doctor as your insight scores are too low.’

Does or can insight change over time, with experience? Can it be learned or acquired? What is it that makes someone see the feelings as another as so significant as to be physical, rather than an optional extra?

I don’t propose to have an answer to this, and I would be interested to hear what people think.

Or, failing that, please tune-in on the iPlayer.

Have a good weekend.

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*This will be taken-off the iPlayer in 5 days… Be quick!

What we are losing and what we will gain

I watched

Attenborough’s programme last night.

 

Climate Change – the facts.

 

My daughter called me in

As

This was the second time

She had seen the bats dying

And the rescued babies.

 

What could be more pathetic?

 

The four of us sat,

Listening to the words of the scientists,

Patagonia jumpers and old jackets

Guarding against the cold.

 

And reflected on our lives now and tomorrow.

 

Climate change;

Catastrophe

And chaos.

 

How easy it would have been

Had the world begun

The adaptation

30 years ago

Before

We reached the state of now.

 

And,

Greta,

Magical girl

As if conjured from

the Moomins (a separate Scandinavian species),

mixed-up with Pippi-Longstocking.

Leading the way.

 

All this made me think of what we must sacrifice in order to create or allow a tomorrow, not necessarily for me, but for my children and their offspring if they have the privilege of parenthood; we are currently in the process of transitioning from meat to not even  a dairy diet – we’ve switched to non-cow milk and no more beef or chicken or sausage; no burger no precariously sources salmon or prawns; it is an effort. And with this, the desire to buy local. For whatever reason I hadn’t realised that onions were from New Zealand; for sale beside those grown in the UK and what else had travelled half-way around the planet for a few seconds of frying? The containers, they say, ‘not currently recyclable,’ when they are open and honest; most are just silent, hoping you won’t notice and within this my original frustration back, when was it, that M&S moved to charging for plastic bags. I’ve never had a problem with this, indeed, back in the 90’s I used to walk to the supermarket with rucksack and load-up, it is the hypocrisy – pretending to care, yet sourcing your goods from everywhere; yes, it’s all a balance – although what would the Maldives farmer prefer? I buy his coconut, or we stop his home from vanishing? What must we lose in order to gain longevity of our species? Burgers, driving to work, inefficiency, waste, inadequacy, new clothes when old will do, holidays to Spain or the Costa del whatever; most of these things I can accept. I don’t know the environmental impact of reading a book; perhaps better to buy second-hand, I haven’t a problem with that. It might make life more interesting. And, healthcare, where does that fit-in; for, you see, anything is possible if we are aware of the issues, if we consider the waste and our rate of consumption. We have gained the internet and my being able to pull-up an image of my family across the country or the world on computer screen or warm water and soap or comfortable clothes and shoes, and what would I give to see a hedgehog in my garden again?

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Wild Garlic associations

I walked through a wood today

and tasted

wild garlic

tangy

rich;

It made me feel

connected.

 

Wild Garlic

Has the Latin name Allium ursinum.

 

Allium as it belongs to the onion family

and

Ursinum, as it is believed that once

when bears

wandered Europe

They would dig for the roots.

 

One of my favourite medical anecdotes

Relates to the use of the drug

With the beautiful name –

Ursodeoxycholic acid

used to treat

Primary biliary cirrhosis;

an auto-immune condition of the liver. (nothing to do with the drink).

 

Urso here refers also to bears

as

Their gall bladders used to be

Tapped

With a metal straw

To extract the liquor

for

therapeutic purposes;

Nowadays they can do this in the lab.

 

Ursula K. Le Guin, writer of science

Who died last year

And

Ursula Andress

Of James Bond fame

(still going strong at 83)

Are the most famous people I can think of

with

the bear

sobriquet;

 

And,

Ursa minor

And

major

That

As a boy

In a garden in Glasgow

My brother tried to explain;

 

Before the sky became too bright

To be black.

jordaan mason

Leaders and Commanders

I am not a military guy.

Anyone who knows me likely would agree with this statement – in fact, if you have met me, you would almost certainly wonder why a) I have even said it and b) Why ‘Commanders’ is in my title.

Well, I’ll try to explain.

It was an unusual Bank Holiday today; I woke around five, saw that it wasn’t raining and decided to head-out for a walk with my dog.

Plodding around Langold lake as Canada Geese oversaw their chicks and a Great Crested Grebe glided past, I began thinking about the position that leaders are meant or should take and what happens in practice.

This actually linked to my blog from the other day when I was challenging the idea of hospital staff wearing uniforms; Freda commented about the necessity to help identify different members of the team in a complex environment such as a hospital.

There is some truth in this, although usually uniforms usually only serve the purpose of batching people into groups; as to what those groups are, the only people who tend to know are the senior nurses who determine the uniforms in the first place.

Whenever there is a decision to alter or review uniforms in hospital (something that is usually applicable to women more than men as for all there are many men working in hospitals, those wearing uniforms seem to be female) – I’ll try to find some data on this to ensure it isn’t just my bias. (77% of NHS staff are women according to NHS Employers, and 80% of them are nurses, carers and other professions allied to medicine – physio, pharmacy, etc.).

Anyway, there are usually specific senior nurses tasked with looking at different colours, designs, swatches and so on, to determine who should wear what, when; in the better places there is sometimes a consultation as to the shade of blue or grey or orange – then there is a decision made by the head nurse.

Again, head nurses can be men or women although I have never encountered a male head nurse overseeing a uniform change;

Maybe like me they believe that these things don’t matter that much, but who am I to stereotype?

And what follows is a slow process of change with people complaining about the green or the purple or whatever.

The thing about all of this, and I have to admit, my experience is only limited to a couple of decades at work in hospital, always as a bystander (the only nearby hospital that has uniforms for all doctors, as far as I know is Chesterfield), is that although there is often a consultation, the final decision is usually made at the top.

And this is the point.

Is this the role of leaders?

To be the final arbiters or decision makers?

Isn’t that commanding?

You see, to me, the role of a leader is to, well, lead. To go in front, to go before everyone else, to take the initiative; placing themselves in the line of fire if that is what is required.

I think of Blackadder Goes Fourth; sending Tommy over the top as the commanders sit  back, play bridge and drink schnapps.

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Who then would be a leader?

Well, perhaps that is the point.

To be a leader should take some guts; it isn’t about how many badges or how long you have been in the seat, it is the risks you have run for your people, the distance you are prepared to go to test a new system or idea.

There will always be people who will do what a ‘leader’ says. Hierarchy and authority facilitate this in a multitude of ways, yet, is that what we want?

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Do as I say, not as I do – a phrase originally attributed to the 17th Century English polymath John Selden in his book, Table Talk published in 1689, thirty years after his death – I guess this was him leading, not commanding!

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Some might say that this is unworkable democracy; others I have heard express, ‘Leadership isn’t a popularity contest,’ suggesting that to lead you have to make decisions that everyone disagrees with; Theresa May has that down to pat.

Populism is where the majority get to determine what is right and wrong; that is Brexit and that was Nazism – no, we don’t want either of those.

Who am I kidding?

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This topic is written about in countless books often found in the management section of Waterstones; A whole journal, Harvard Business Review is obsessed with the concept. I am not going to sum it up here.

I can however express my opinion.

Leaders should go in front; there you go. They should be willing to undergo the same challenges, discomforts and struggles as those they intend should follow them.

Don’t pretend to lead when you are commanding – it doesn’t work; it just makes people frustrated and results in frustration.

As to whether going first, jumping out of the plane before everyone else is sufficient to bestow the title on an individual, I doubt; there has to be more – perhaps adding, caring, compassion, intelligence and most importantly a sense of humour.

Then you are getting somewhere.

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Four days, workforce and GP appointments

I just read a BBC online article about a four-day working week.

This has been a thing in business and productivity circles for a while.

Essentially, pay people the same as they would earn in five days (what most but not everyone works in the UK) and instead allow people a day off; they choose the day (although not everyone can have Friday).

The Wellcome Trust tried this as an experiment and although it had benefits it wasn’t overall successful; there were issues with the specific day, concerns about squeezing five days’ work into four and other things. They are having a pause.

I was talking with my older brother last night; he has taken this model to an extreme, and, his working week is Monday, Tuesday and Thursday.

I don’t know and haven’t asked about pay.

The thing is, he described, he gets two weekends in the one week; It is a way of re-framing what he is doing that at the moment, at least, is proving fun.

This all makes me think of doctors.

I suspect it applies to people across the workforce, mostly because of changing priorities and lifestyles.

It began in the past and is now slowly ebbing.

This is the notion that you work hard; say, ten-hour days, five days or six days a week and you die when you are 72. (The previously economically expedient model for society).

I guess in some unlucky parts of the world, this is still the case.

In the UK we have moved-on (although recent gains if life expectancy have dropped-off (thanks Tories), I am sure it will be a while before we start losing decades of life. (Again, you already have this decade of life-expectancy difference in most UK cities between the affluent and the poor).

Another brother, recently retired.

He worked as a GP for the past 40-odd years.

Full-time, flat-out.

Anyone who has read the news recently or who works in the NHS (or might have read my previous blog) knows that there is a workforce crisis.

The reasons for this are complicated – for example, although there is something like 40,000 nurse vacancies in the UK, most of these are filled by nurses doing additional and frequently agency shift; that is, nurses who prefer to work via an agency than directly for the NHS. As above, the reasons are complex.

There is also a medical workforce crisis.

This seems odd as more doctors are being trained than at any time. Over the past few years new medical schools have opened to cater for this demand; and with this, our population health is supposedly getting better (Tory meddling aside), how come?

Well, part of this reflects an acceleration in the rate of retirement of doctors (above) and, part the decision by some to work less than full time.

In the past the group of people this mostly affected were women with children (yes, another inequality in our society; also for another day), now it is increasingly common (although I don’t have the figures) for people without children to opt to work less than full time.

Figure 1_ Summary of UK labour market statistics for September to November 2018, seasonally adjusted (1).png

Of course, in the UK this impacts on the availability of doctors when you want to make an appointment or hospital rota organisers when they are trying to balance the books.

People realise that there is more to life than working those fifty (or sixty) odd hours a week and having nothing left-over;

So, the net investment in more doctors (and nurses and therapists and pharmacists) training is we stand still.

An alternative approach might be to make work more fun, address the stressors of work – what makes it hard to undertake a twelve hour shift (as many nurses in the UK do routinely) – the answers to this again are complicated, but you might start with the way that people experience work; how they are treated, the degree of autonomy they have over the simple aspects such as how they dress, the colour of their hair or shoes; in most UK hospitals you get shot if you are wearing a wrist-watch, on the background of no evidence.

On some hospital wards a nurse sipping a cup of tea is an anathema. (Doctors still usually get away with this), physios can wear trainers, but consultants not, all sorts of rules and regulations that are based upon pre-conceptions and old-fashioned ideas of what is OK and what is not linger in the workplace.

We need to relax.

To really see what matters; yes, this is back to What Matters to You – and indeed, individual preferences. Some people will prefer to work excessively, that is their choice, indeed, for some people that works for them, others want fewer or more flexible hours.

This is important, but what is equally relevant is how we treat our staff during those hours of work or time off.

For all the incredible improvements in Western Society over the past twenty years, tolerance isn’t necessarily at the core.

We see ‘the other’ as a threat, and when this other becomes your neighbour, the Eastern European delicatessen, a co-worker or your employee, we can’t hope to solve this challenge.

My suggestion?

Well, I believe that hours worked a week is important, but what is more so is how those hours are spent. 12 hours on a hospital ward without a break as happens across the UK every winter (and at other times) for nurses is unlikely to produce high productivity, rather, it leads to exhaustion, a narrowing of focus and ultimately in the worst cases, compassion fatigue.

nurse shifts uk.pngwww.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/06/12-hour-shifts-report.pdf

I don’t believe we can wait for the government to determine what is right as everyone’s situation is unique – this is down to individual employers and employees to have open and honest discussions about what works and what does not. (The government can perhaps regulate that people have to treat their employees with respect, dignity and caring – the details need to be done locally).

In some instances, this will be a shorter week, in others, more flexibility, ad hoc days off, short-term holiday requests, variation in dress (why do we make people wear uniforms? Who in this world is uniform??!)

It is the opposite of the changes happening in our global society, where we are identified as fractals in the hive; it is undoing this anonymity and making us once again individuals, or perhaps, for the first time, acknowledging our identity, uniqueness and contributions.

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Here is the original BBC article.

 

The Sound of the Sea

Yesterday I attended an unusual event at Sheffield Hallam University. It was different for me as I had not visited the campus before and sitting in a room with academics is not how I usually spend my free time.

The meeting was part of a series of workshops called ‘Critical Arts in Health’ organised by health/tech/art superstar Smizz and colleagues undertaking PhD’s at the University.

The theme was ‘Emotional labour in health care – the affect of words’

As with most things I become involved with, I’d read the headline, found it interesting and attended; I tend not to have time for the small-print – which at times can cause problems but, for the most part leads to an interesting if not fun experience of life.

Joan who was leading the session discussed some of her work involving occupational therapy students and their experiences of learning and care, some of which is delivered through the medium of creative writing.

If any readers were medical students with me back in the early 2000’s you will remember the creative micro-projects you undertook focusing on older people – delivering poems, plays and paintings as a means to gaining a deeper understanding of our relationships with our patients; had I known Joan back then it might have had more impact!

One of the exercises which I hope to recreate here (and you can do too) was in the form of a quick poem; called, ‘These I have loved’.

The idea is to write a poem with each sentence or phrase based on one of the five senses;

It chimes well with some of my ideas of this blog which are a type of blot on the landscape of my life; a semi-permanent mark. My kids, if they are interested can look back on what I have loved when they are old.

Maybe you could have a go.

I’ll come back to the sea at the end.

Here is my attempt;

The sound of waves on the shore on a beach in Scotland.

The smell of my mum’s cooking, fusty old books and men in damp synagogue raincoats.

The taste of gefilte fish and mum’s chicken soup.

The touch of soft, fresh off the line pillowcase on summer bed.

The sight of early morning sunshine that anticipates a day outside.

Yes, not necessarily my best, but probably says more about me than lots of what I have written in the past.

Something I found very interesting was that the person sitting next to me opened her poem describing the sound of the sea. I wondered whether this was just coincidence or perhaps related to our land-locked lives in South Yorkshire, where to reach the coast you have to travel.

Maybe not.

What do your senses tell you?

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On the stroke ward, breast cancer and other experiences of care

I remember, many years ago, attending with my mum, the breast clinic at a hospital in Glasgow.

We were getting the results of her biopsy.

Although the event was traumatic, the waiting-room sticks out in my mind.

They had a special place for patients to wait for results and an attached corridor and room for the same people after they had seen the doctor; I think this linked with a way to avoid over-distressed people who received bad news intermingling with those who either had been given the all-clear or who were still in the dark.

It was a way of controlling fear and anxiety.

It possibly led to more.

More recently, visiting a stroke ward I reflected on the experiences of patients.

Stroke, still a devastating disease for which although some cutting-edge treatments exist – thrombolysis, embolectomy, for example, most people, who are older, with multiple pre-existing health conditions are exposed to care plans that have not changed in decades, that is scrupulous nursing, intense physio, occupational and speech therapy and, time.

What do you think when you are on the stroke ward, after having experienced what might be considered a relatively mild ‘event’ – say, the power in your hand is lost for a few days, which returns with no complication and the man in the bed facing you has lost all of his speech or his mobility has been wiped-out, requiring hoist transfers, attached to nasal or other forms of nutrition and hydration?

‘There but for the good grace of God, go I?’

Or, is there a deeper defence mechanism which doesn’t even allow for this consideration.

I remember, further back in time as a 16-year-old visiting my grandfather in the now relocated Jewish Old Age Home on Newark Drive in Glasgow.

He, an otherwise fit 80-year-old and I would sometimes sit in the gardens sipping orange juice; was always very cautious about taking me into the dementia section. I can’t actually remember what he said, perhaps something along the lines of, ‘those people,’ in an attempt to separate their needs from his.

At other times we would travel in the lift with colourful characters who could easily have been from Danny’s Deli on the Lower East Side.

Some of this perhaps connects with a deep contagion instinct; stay away from those who are sick as they might pass-on the lurgy.

(I won’t even go-into my experiences of ‘Jew-Bug’ as a child in Glasgow)

Fortunately, in recent years barriers have come-down and there is a better understanding, although it didn’t take long following the outbreak of Ebola for UK society to flip-back.

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As a doctor I am somehow immune to this – I think.

I usually stare into the eyes of another person and that tells me all I need to know; any physical, psychological or other impairments fade-away in the moment.

How powerful the images of Princess Diana embracing children back in the 80’s.

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Overcoming our own fears, preconceptions and biases is surely a hope for the future as we continue to grow as a community.

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Robot Sushi

I was sitting in the car with my son the other day; he has recently given-up meat in an attempt to support the ecosystem.

He was munching through Sushi.

Nothing fancy – the type you can buy half-price from Tesco if you visit just before closing.

‘Do you think this was made by a human?’ He asked.

I’d never really considered who made my Sushi; Indeed, when I eat any processed or shop-bought ready-meals, I tend not to consider who makes my food, let alone where it comes from. Yes, I should check for free-range, organic, fair-trade, etc;

I think the point was valid. (And astute, but I am biased).

It was only recently that the benefits of say, chopped mango to developing countries became a thing.

Essentially; if you buy chopped mango, it is prepared in a mango growing country – I think they are quite popular in India and Bangladesh. The folk growing the plants can peel and chop-up the fruit before popping it onto a Boeing 747 heading to Heathrow. The peel, stone and other bits you don’t want to eat are turned into compost and the fruit is sold at a premium. Everyone wins. (Although I am sure the supermarkets win the most).

Similar strategies apply to coconut, pineapple and other tropical fruits.

I guess if you are going to contribute to global CO2 emissions, you may as well ensure that the profit is evenly spread.

Anyway, this, is where humans in the UK benefit humans in India.

I don’t intend to go into more detail as this could become a rabbit-hole of tinned/preserved/dried/frozen foods, ending in a debate about Veganism.

The point is the humans.

How long will humans in India continue peeling and chopping?

When will the robots step-in?

Indeed, when will the robots replace the rest of us?

Algorithms already exist that are more accurate at interpreting x-rays than any doctor or radiographer; how long before this applies to everything?

Going back to my son; he recently wrote a short essay on this subject relating to the challenges of artificial intelligence for his GCSE.

When I was 15, I used to worry about basketball, girls and Bruce Lee. The existential threats we give our children are really tough.

Most of us, if fortunate enough to have the financial wherewithal, will pay extra for organic carrots (my favourite organic) – how many of us will pay more for ‘human made’?

I would certainly prefer the Sushi to have been handled, chopped, diced, rolled, or whatever by a person in Sheffield or a processing plant somewhere in the UK than a robot churning-out soul-less replicants of smoked salmon and hake.

How close are we to this happening?

Already you can get a named person on your bottle of soap from Lush; how soon will this apply to our sausages, kebabs or doctors?

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Conscious pigs

Before I begin, I will say that I have not read any of the science, pseudo-science or even tabloid reports about the pig brains that have been supposedly, transiently, restored to function.

I watched the TV news last night and listened to the BBC World Service this morning.

The phrase that caught my attention (beyond general considerations of what happens when we die) was the journalist saying, ‘And, I must emphasise, there was no restoration of consciousness in the pigs.

Yes.

Consciousness.

Yesterday I wrote about the risks of delving too deeply into either the internet or Kabbalah; it was at another of those lessons when I was in my early teens that a teacher tried to explain that animals don’t have emotions.

For whatever reason, he chose dolphins.

Now, there is a long debate about the emotional side of animals. Anyone who has read my blogs likely knows that I am firmly on the side of anthropomorphism and animal-emotions.

There is a theory that it is all learned-behaviours; my dog smiles because she knows that holding her jaw slightly open, letting her jowls relax and projecting her tongue evokes a response in me.

No.

I think at these moments she is happy.

You can argue all you like.

Professor Skinner.

But, does my dog possess consciousness?

To answer this question, you first have to determine what I mean by the word.

I am clearly not awake when deeply asleep in the non-REM phase of the night.

Am I unconscious? Do I lack consciousness?

If you give me a nudge I usually stir.

Is this being returned to consciousness or merely awoken?

In an operating theatre, with muscles paralysed, and a ventilator doing the work of breathing, powerful anaesthetic agents send you into a state of unconsciousness (from which most of us never hope to stir, particularly if the surgeon has her hands in your tummy).

Is an anaesthetised pig unconscious?

What is a pig thinking when he or she waddles around a field sniffing for grubs?

In general, I have little experience of pigs.

I have seen them at Cannon Hall, big mammas and tiny piglets.

When the children were young, family and I used to love visiting the Kune Kunes.

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Yet, what are they thinking? What are they experiencing?

Intelligent, yes, but is this consciousness?

They are awake; the wander over to say hello when I approach, but do they know they are on a farm? Do they know they are destined for the abattoir?

Do the pigs think about thought? Do they fret? Do they consider their position in the universe, reflecting on the past?

Clearly the brains rejuvenated by the Yale scientists were not worrying about their next move.

This was just neurones firing, synapses joining-up and cellular activity.

When we die our cells don’t stop.

Things continue.

Mitochondria transfer energy, our muscles respond to stimuli; as to whether our hair and nails grow, I have never checked although I am told this happens too.

We stray back to pseudo-science and science-fiction.

The Cyborgs are attacking!

It is very possible I am missing the point and, the guys at Yale have done something more miraculous than I can imagine; not just extracting brains from slaughtered pigs and dunking them into a fancy liquid.

If this is the case, please accept my apologies.

But, consciousness?

another kune.jpeg

The Age of Information and The Last Kabbalist

I remember as a 13 year old, attending a lesson at my school – the subject had something to do with the bible; probably Rashi – (Rabbi Shlomo Itzchaki – a 12th Century French Jewish sage); he wrote very detailed commentaries on ancient Jewish Laws – that is, interpretations of what the explicit biblical rules and regulations mean, sort of, the meaning behind the meaning. All very cryptic.

Here is what a page looks like in Hebrew:

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It is so complicated, there are commentaries or commentaries of commentaries.

Rabbi Z say, Rabbi C says that Z said, Rabbi D said that what Rabbi Z meant was different to Rabbi C or A and…

Anyway.

My point relates more to something the teacher mentioned in a passing comment about Kabbalah.

Now, some of you will have heard about this in relation to Madonna the singer and others, from novels by folk like Dan Brown. Essentially, Kabbalah is Jewish mysticism, magic, spirituality, philosophy and sophistry all mixed into one enchanting system.

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It is one of those things that Bruce Lee (not mentioned him in a while!) would have called a circle without circumference.

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I don’t know a great deal more about Kabbalah than what I have written (oh, yes, there is quite a good novel by Richard Zimler called ‘The Last Kabbalist of Lisbon’ which I recommend).

last kabbalist.jpegGetting at last to the point is what the teacher said about Kabbalah.

Seemingly, only adults (and, back in the 80’s that meant old men) were allowed to study the sacred texts, and, only men over 40 years. Under this age, and the subject matter was considered too powerful – the most commonly used analogy being, ‘like wandering into a dark forest and losing your way,’ I think this is shorthand for, ‘If you study this stuff at too young an age, before you are adequately fixed in your ideas, you risk insanity.’

Suffice it to say, despite having now tipped my fourth decade, I haven’t risked venturing-in; also, there is too much else going-on in my life.

How you ask, does this relate to the information age?

Or, perhaps, Information Age, with capitals, to give it its due.

Well, I am coming to the end of the mammoth audiobook, ‘The Age of Surveillance Capitalism’ written by Shoshana Zuboff.

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I have mentioned this in a recent blog.

The book is a masterpiece, covering all aspects of the internet, how the tech giants, technologists, governments and capitalists in general have entered into a new age associated with the growth of social media.

I don’t necessarily recommend the book as it is so big; perhaps Shoshana could write a mini-guide?

What the book touches on in particular is the way in which technology has advanced to such an extent that no human is able to comprehend the enormity of either the computational ability of computers (and when I say this, I don’t mean ‘Deep Blue’ sitting in a museum somewhere, more the networked, globally connected, what Zuboff sometimes describes as The Hive (both I believe in relation to how our society has made us information collectivists like bees and also the way the whole miraculously works together.) (Like the recent shot of the black hole using global connected, computer imagery.)

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Now, the computers are still controlled by humans, although every time I or anyone interacts with technology, be that a phone, PC, internet-enabled TV, fridge or car we are generating information that can be mined and translated into data that can then be ‘rendered’ in Zuboff’s terminology, into material that is sold by social media companies to increase profit (advertising mostly).

This again, is sort of OK, heck; if I don’t know how to spell ‘supersede’ (NK), and the computer knows that people who can’t spell this word and who have a hundred other specific foibles of typing, net-browsing, driving habits and so on; essentially, the computers are at the point of understanding me and knowing everything about me and what I think or might think in the future.

(It only takes 20-odd Facebooks likes to determine your personality type more accurately than any standardised tool).

You can try this out on your phone;

Go in to Whatsapp or the text app and write; ‘I’ this is then supported by a string of words based on your past browsing and typing habits that either Apple, Samsung, Google or Facebook have processed and predict what is next;

For me, for example; I.. have.. ordered.. the.. chicken.. soup.. for.. dinner.. tonight…

As to what this says about me and chickens, I don’t know.

Yet, who has written this sentence? Me or Apple? Is it based on my ideas or those of others?

Where does this end?

Do you see where I am going?

It can get a little crazy.

I watched ‘Bodyguard’ last night on TV – it is a UK conspiracy thriller/suspense involving government, security, organised crime, Jihadis and others;

Central to the story is the implementation of ‘RIPA 18’ a Parliamentary act which would allow the government access to all information, to prevent terrorist attacks.

Every time I walk down the street, CCTV’s capture my image and, their ability to detect me, my facial features, gait and so on is now so sophisticated that if you are sitting in  a Google data-store, or you have hacked into Google, you can work-out where I am and what I am doing at any moment in time; If I pop to London, the software can track me.

Is this a bad thing?

Well, in myself I feel this to be the case, although I as yet do not know enough.

It is however a reality.

Remember in The Matrix where Neo takes the Red/Blue pill?

That is stepping into Kabbalah, and, so too, with the potential effects of knowing too much about the potential of technology to control, analyse, nudge or coerce us into action or inaction.

I think I am too young for all this.

Genug!

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Flow; best left to plumbers.

It perhaps has something to do with my internet settings or preferences, I don’t know; you see, I get a number of emails from different national and international health organisations informing me of conferences and award ceremonies taking place in the realm of Quality Improvement.

This is the science of doing things better in health and social care.

It sounds straightforward and, yes, it is.

Examining what works, measuring, adapting, trialling something different and going round and round again in a virtuous cycle of improvement.

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Add a soupçon of creativity and you might be on to a winner; as they say.

My question about settings relates to the relatively narrow remit of subject matter covered in these communications – flow – how to ensure your patients stream through the hospital system, how to maintain an effective emergency department, discharges before breakfast, improving your delayed discharges, seems to dominate.

IHI flow.png

The theme is how we can make acute hospitals more effective; you see, in many instances over the past decade there have been phenomenal improvements in care in hospital – deaths from falls, health care associated infection – MRSA and C. difficile in particular as well as drug errors have all declined dramatically.

When I was a junior doctor, it was expected that patients would develop C. difficile diarrhoea if given enough antibiotics; in some departments this has been eradicated.

Yet, we can’t fix flow.

The reason for this relates to the blog I wrote earlier today – flow, or, the movement of often frail, older people who are experiencing a multitude of complex long-term problems is in the realm of complexity. Sometimes described as Wicked. No one thing works; you need to have Adaptive Solutions – what works for A might make B worse and vice versa. Humans are complex and the systems of care in which we endeavour to provide support are even more so.

Again, I am not really getting at this as an issue, it is more the system bias towards flow that frustrates me.

You see, flow is important, especially in relation to having enough beds available to stop the A&E department overflowing or allowing for elective hernia repairs or hip replacements, but in the overall scheme of things, it is relatively trivial.

And this is my point.

Most of health and for that matter almost all of social care take place outside hospitals.

In the community.

More patients are treated in one day by GPs, community pharmacists, nurses and social workers than are seen in a month in hospitals.

Yet, we tend to focus on hospitals as if everything else is unimportant.

It is Nero fiddling whilst Rome burns.

The real issue is how we support and care for people in the community;

I am not saying that hospitals are unimportant – they are, and I and everyone in society benefits from them, it is just that attention is focused in the wrong place.

Quality Improvement in relation to care in the community; how patients and care home residents are supported would likely provide a far higher return on investment, yet, the light is shone on the hospital; it is in the spotlight, whether driven by media attention or political angst.

We need to find a way of turning this upside down;

I am planning to support a revolution of care in South Yorkshire… Please watch this space; in the meantime, let’s lobby the Don Berwick’s, Albert Wu’s and a host of other secondary care based professors to lift their gaze from the operating theatres to the primary care clinics, care homes and living rooms of older people and the citizenry where most of the work of the NHS and social care happens.

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Adaptive Intelligence

A recent adventure took me to Devon on a course run by Claudius van Wyk, Michelle Le Vieux and Jane Pightling under a banner of Evolutionary Transformation, over the two days we examined something loosely described as an issue within our ‘problem space’.

I can’t actually begin to describe all that we covered – it was an intense experience and I am still letting the ideas bed-in to my consciousness; some of it profound, dealing with aspects of Complexity, Holism and Spiral Dynamics – please look them up on Wikipedia if you want to know more.

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What I would like to focus on here, at least at this stage of my understanding is the motivation that led me to travel all the way from Yorkshire to the South Coast of England.

I think a big part has to do with appreciating that first the world is changing and secondly, I am changing.

Now, it is quite evident that things are moving-on; this is being alive, participating in the human race; as to whether the changes are more rapid than in the past is hard to say.

I wasn’t around 100,000 years ago, so my limited experience is, well, limited.

That I am changing is also fairly obvious; whether I like it or not, even the most conservative, not in my back-yard person is changing.

Our physical, emotional and psychological selves respond and adapt to the world around us.

The melanin in my skin reacts to the changing seasons, my heart counts-off the number of beats allocated to me; my digestion grumbles on, I move from here to there. You smile, I respond; it is a constant flux of being, doing and changing.

My sense, or, at least my experience over the past few months is that I have awakened to the necessity for change, not just in myself, but in the system in which I operate, and, for much of the remainder of my life this means work, or the care, treatment and support of other people; sure, there is more to my life than this, but, reflecting on the Adaptive Challenge – my problem space is mainly within this context.

I have long witnessed unhappy, dissatisfied people at work.

I remember a couple of years ago looking at a group of five hospital matrons; the senior nursing leaders of the organisation, they were attending a staff meeting and they all looked knackered.

Their eyes were dull, tired, their postured stooped; they emanated nothing more than a faint flicker of a need to keep going, to survive today in order to continue the next.

I have seen doctors like this, therapists, indeed this is almost a feature of those who work in health and social care; clearly not everyone all the time, but that draining of spirit, the erosion of life that surely is not what anyone planned when they started working or applied for a university or college course.

Is this just the way it is?

Is the extinction of your energy part of the contract of employment?

Do you live to work?

Do you work to live?

Neither I believe are what we want.

And it was this question that brought me to the course;

Surely this isn’t all there is; not necessarily in a spiritual sense or even a hippy, we can all get along and love-in way.

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More, a belief, that if the world is changing, if technology and the advancement of science and thought are progressing, and there are some amazing things happening in the world beyond Smart Phones – literacy rates are increasing, life-spans, fertility rates falling, we have treatments for HIV, vaccines for Ebola; cancer and heart disease are no longer the killers they were. Although we have jingoistic leaders rattling sabres, we don’t have Passchendaele or The Somme. Food is safer, even little ducklings still waddle past me as I step-out on Sunday morning.

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There is good out there.

Yet, if there is so much good, why does it at times feel so bad?

And why, particularly is this such a focus within communities of individuals working in the already mentioned health and social care?

Surely these should be the most rewarding, satisfying occupations;

Perhaps part of the problem is that we, or rather, the system has not adapted?

If we provide elements of 19th or 20th Century care to patients in 21st Century hospitals, it is inevitable that something will go awry.

I haven’t mentioned the End PJ Paralysis campaign in a while.

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It is still alive and growing as a global movement.

Yet, I walk into a ward in any hospital in the country and a significant proportion of people will be in or on their beds, wearing PJ’s, passively receiving meals, medicines and records of their heart rate, blood pressure and oxygen saturations.

We apply the same factory mentality that existed when Titus Salt built Saltaire in West Yorkshire in the 1850’s to the world of 3D-MRI and laser-guided surgery.

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Our working practices are unchanged; people clock-on and off, they must obey rules and regulations that are long past their sell-by date, mostly, just, because.

We need to determine our problem space – this is the aspect of our lives that provides us with the most significant and meaningful challenge, and, once it is defined, worked-out, dissected, analysed from as many angles as possible (perhaps applying a multidisciplinary interpretation), we can do something.

We don’t have to turn on, tune in and drop out, more turn on and change.

This is evolution.

Not perhaps in the sense that Darwin might have described (although I am sure if he were around today, he’d be up there with the greatest thinkers in the field).

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If we don’t adapt, we die.

No one knows what the future holds; one thing however, is certain, that with access to more information and means of communication than at any time, we have the opportunity to seize the moment and adapt, to determine what we want, what is right and what needs to evolve and change.

We might complain about working practices in hospital – yet, who are the people who determine those practices? Yes, us.

Not everyone is in a position to contribute, and not everyone even sees the issues, that is just the way we are.

Yet, those of us who have determined that something must happen, something must change, have a responsibility to speak out.

I’m not sure if this has at all explained the Evolutionary Transformation – I am sure others could put it into more meaningful terms and I am definite that those who don’t know about Adaptive Intelligence will not be any the wiser; I guess I need to get a better grasp of the concept before explaining to others.

In the meantime, please enjoy your Sunday.

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Health Care Support Workers (Jean Bishop II)

Thank you to my friend and avid reader Freda for pointing-out something I had missed in today’s blog about the Jean Bishop Integrated Care Centre in Hull.

‘So many assessments – completed individually or as a panel? Tiring? Was thinking Doris would have to stay overnight?’

That was her consideration of someone visiting the centre and undergoing multiple holistic assessments. It is all very well being thorough and covering all bases, but, if you are frail and don’t get out much even a four-hour session seeing different people is likely to wipe you out.

I am not sure if they have been collecting data on this aspect of the process. (I’m sure they are).

Earlier, I didn’t mention some team members who are fundamental to the assessments at the Jean Bishop Centre, who conduct a preliminary review, at times in the patient’s home on a day different to their visit;

I didn’t mention this group of staff and on reflection that is inexcusable.

Indeed, you don’t see much about Health Care Support Workers (HCSW’s) in the media – they are a cohort of staff, fundamental to the running of the NHS, present in hospitals, clinics, care homes, GP surgeries and anywhere people interact with care.

Not only this, HCSW’s are actually of us much importance to the effective operation of the NHS as nurses and doctors, as without them, the system would collapse – to a greater extent than any effects of Brexit or immigration restrictions.

HCSW’s are the staff who help you get dressed in the morning in hospital, they might bring your meal or take you to the loo; they also might take your blood test, dress your wound, check your blood sugar or perform an ECG, complete a health assessment or dementia check.

HCSW’s are the eyes and ears of the clinical team, conveying essential information to those they treat and, often they are able to learn more about a patient’s fears or apprehensions than someone like myself as there isn’t necessarily the impairment of hierarchy; having ‘doctor’ before your name is useful if you want to prescribe medicines, order x-rays and remain genderless in the eyes of the internet, it isn’t fantastic at breaking-down walls and bringing people together.

I believe a person is more likely to relate What Matters to You to someone who is a HCSW than to a doctor or nurse.

You talk to your friends and family; you don’t easily share anxieties with those in authority.

I may be getting off the point, but I feel this is very important.

Beyond this is the reality that what was once considered to be within the remit of a doctor, nurse or therapist ten years ago is now considered de rigueur for a support worker; when I was a medical student, if someone needed an ECG, you’d call the junior doctor; administer a medicine or test, call the nurse or doctor, monitor mobility, transfers in and out of bed, leg length discrepancy and all that, the therapist.

Things have become more democratic these days and, sensible.

I will not mention the pay discrepancy; perhaps that is for another day.

You discover that you don’t need to have a degree in anatomy and physiology to determine that someone is in pain and needs something done or a qualification in dermatology to identify a dodgy rash.

Thank goodness for diversity within health and social care, without which we would fail.

So, yes, HCSW who beyond training more doctors and nurses are central to us all getting along and receiving the care and treatment we require.

Thank you.

Here is a list of some of the tasks a HCSW can undertake – please feel free to add-on below;

Syringe ears

Apply dressing

Clean a wound

Stitch a wound

Take blood

Give an injection

Test for dementia

Test for depression

Test urine

Assess wellbeing

Assess mobility

Deliver physiotherapy

Support occupational therapy

Coach

Treat anxiety and depression

Reassure

Care

Kiss / hug

Laugh

Smile

Assess pain

Reassure

Explain

Teach

Support people living with dementia

I need help with some of these details; I am showing my ignorance, so, please help.

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Jean Bishop (*warning – graphic images!)

Recently I went to the Jean Bishop Integrated Care Centre.

In Hull, this recently constructed state of the art health and social care facility is leading a new revolution in the ways in which care, support, diagnosis, investigation and treatment can be delivered outside the walls of a traditional acute hospital.

I won’t make this negative by running-down big hospitals; they are incredible – temples to medical science.

(As an aside, did anyone watch the programme on TV last week with surgeons in Birmingham? It was stunning. Here is the link).

Anyway.

This TV programme actually brought something quite relevant into focus; that the two worlds of support for older people living with frailty and complex medical and social conditions and the sophistication behind replacing a 70-year-old woman’s aorta are quite separate.

Each requires skill, knowledge, passion, excellence, but of a different type.

Not to get too graphic; this kind of thing:

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I am getting ahead of myself. I haven’t told you about the Jean Bishop Centre.

Situated in a housing estate in Hull, it was built on the site of the former David Lister School.

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The centre provides, amongst other things, a one-stop-shop for older people, providing a holistic, multidisciplinary, health, wellbeing and social care assessment.

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Dan, the doctor in charge showed me round and explained the ethos, which focuses on identifying those people living in Hull who are older, with complex health needs, often with associated frailty, providing a thorough assessment and support plan.

I’ll give you an example.

Say, Doris (this is made-up), visits her GP after having fallen at home. She is 88, lives alone and has a long-list of heath conditions – diabetes, osteoporosis, atrial fibrillation, asthma, hypertension, heart disease, previous cancer; this kind of thing. She takes 20 different tablets.

She lives in a 1920’s terrace house; the stairs are steep, the kitchen small.

Her one son lives in Hastings.

Three of her closest friends have recently died.

She struggles.

Under normal circumstances, utilising a bizarre referral management system in place across the UK, Doris wouldn’t qualify to attend the a fall’s service, where there would be detailed assessment into why she fell, how to prevent another, that kind of thing.

In some areas Doris would have to fall twice more before meeting the criteria for ‘frequent faller’ and hence attend the clinic.

Doris of course could be less fortunate and break her hip. This would be terrible for her, it would risk her future independence, let alone all the risks of surgery, pain and so on. She would however meet a multidisciplinary team of surgeons, physicians and therapists, albeit in an acute hospital as they put her back together again.

Not really what anyone wants.

The GP will only have a maximum of 10 minutes to sort-out Doris’ fall, medicines, social isolation, pain, anxiety; not enough.

At the Jean Bishop Centre, Doris is proactively identified by a nominated GP in the local practice who then using various assessment measures refers her to Dan’s team.

Doris is reviewed by a social worker, wellbeing officer, physiotherapist, occupational therapist, nurse, pharmacist and doctor – sorry if I have missed-out anyone.

A care plan is created online, shared with Doris and her doctor.

Including her preferences for what to do in case; this is part of a new NHS document called ‘Respect‘.

Half of her medicines are stopped as they were required when she was 50 with high blood pressure, but now with the passage of time, are actually contributing to her risk of falling. Bendromefluthiazide, Nifedipine, Betahistine, Iron, Aspirin, all now unnecessary and removed from the repeat prescription.

She is provided with a home assessment which identifies that she would benefit from better lighting, a new cooker and maybe a weekly visit to the local social group.

The team discuss Doris in a multidisciplinary meeting, working out if they can reconcile Doris’ priorities of care (What Matters to Her) with the health and social care landscape of Hull.

Doris even gets lunch as the assessments take a few hours.

Everyone smiling.

There is more to the centre than this, but hopefully you get my gist.

There are different ways of providing health, social care and linking with voluntary sector organisations beyond dragging people to the big hospital with its parking charges, confusing signage and echoes of past misfortunes.

We have been so stuck in our ways within in the NHS, assuming that things must be a certain way, particularly outside the high-tech world of innovation and biomedical engineering, that doing what we have always done seems the only option; ward rounds, outpatient clinics, repeat prescriptions, risk registers, and on, and on.

The world in the past ten years has changed more than in the past thirty, or forty. And the rate is accelerating.

What is OK now will likely be positively harmful in another ten years.

We need to keep-up with change, adopt an agile philosophy towards treatment and care, play to patient as well as staff preferences; use our cultural, community and social assets to realise that we have a wealth of expertise and support in our next door neighbours, in local teams of workers and volunteers.

All it just takes is vision, collaboration and I guess, Dan and his team would say, lots of hard work.

Hard work, when translated into a vision that makes a significant difference is itself transformed, it becomes meaning, its return on investment is not necessarily financial, it is something more profound and longer-lasting.

Doris might be provided a new lease of life with independence, friends and meaning; this better than a few miserable years declining in a care home as so often happens.

This is no panacea.

You see, it is complicated.

Those in the know see that this is complexity.

Future developments might fail and, I know I am getting on to a different subject; it is what matters to Doris that matters.

Patient preference is paramount.

Pathways, processes and flow might support the critically ill on intensive care; for older people, they are more often than not associated with a different image, that of being swept away down-stream, especially if your needs or wants are less consistent with the anticipated norms.

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The Jean Bishop Centre demonstrates a fascinating point in the journey of the NHS; between individualism. Me. And the collective, Us.

Economics might prefer we ignore Me and focus just on Us.

Yet, you, who are reading this is a Me.

Us and Me can be reconciled.

It just takes a little imagination and passion.

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To meet Jean Bishop, follow this link.

Statistic – moi…

Yesterday, I came quite close to becoming another police statistic.

Fortunately, nothing too violent, more of a psychological event – it was cyber-crime.

We hear about this every day.

Essentially, there are two schools of thought (as with everything).

The first, that doing things online is far safer than carrying bundles of cash around with you and going to the shops i.e. Amazon for a book versus Waterstones; the former conducted from my home or on my phone, protected by layers of security and technological wherewithal, and, poor Waterstones – not only do I risk a car crash getting there, I could be attacked in the street, pick-pocketed, and so on.

You get the idea.

It isn’t black and white.

Or, yes, it is black and white, although more Yin and Yang.

Back to my cautionary tale.

It began in Bristol.

Eating lunch with my nephew; for whatever reason we touched on the subject of ‘Junk Mail’ – this is email that is skimmed-off by computer defences as the content appears to the email client ‘dodgy’ – mail offering for me to get rich quick, acquire another aphrodisiac, that kind of thing;

On the flip side, because the technology is clever, but not clever enough, some genuine mail pops into this folder – this is a recurrent theme for NHS email, where the bar is naturally set quite high. And, because of this security, you are sometimes advised, ‘Check your Junk Mail’

And this is where the story began.

I was looking in my folder the next day;

There was a mail from the TV Licence people.

I thought, ‘Oh.’

I realised that recently I had received a new bank card; I assumed, ‘They must need my new details,’ and, the way it was worded, I thought, ‘I’d better do this straight away – you know what the TV people are like.’

(I have never seen a radar van, although I believe they exist).

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It was just after the start of the financial year and this was made more real by a recent run of TV adverts from the licence people showing what might happen if you don’t pay.

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It was classic psychology of fear.

Despite my better judgment, I moved the file into my Inbox, followed the link and input my details.

I guess this would have been bad-enough; supplying a dodgy website with my bank details.

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The real badness happened the following day.

I received a call from my bank;

Now, I have long been one to call screen and not answer numbers from Clitheroe and Cambuslang; accepting that these are usually credit robots.

This was different as my phone gave my bank’s name;

I thought, ‘That’s odd,’ but considered, ‘Well, it must be the bank.’

I answered and was led through a complex fear-mediated routine from the fraud team, acknowledging that I had input my data recently into a fake website (the TV one) and it was their role to fix things.

Heck, when I challenged them they volunteered my name, address and frustratingly (and stupidly on my part), mother’s maiden name.

It got as far as them asking me to log-in to my online banking – yes; I did this.

At the point of the guy directing me to move an overdraft into my current account so they could consolidate the funds and open me a new account that my suspicions increased; that and the flaky internet-enabled quality phone call.

When I questioned further, they again resorted to fear;

‘We need to do this in order to stop the people with your account details from accessing more funds,’ ‘If you hang-up now, we will not be able to guarantee your money,’ ‘If you call back there is an up to 45 minute wait for the fraud line.’

Fortunately, my son was listening-in to the conversation and his internet primed Spidey-sense had worked out what was going on and I ended the call.

Calling the bank immediately afterwards I learned that I had been the victim of cyber-crime and had got-out just in time.

The costs, losing my mum’s maiden name as part of my security milieu; something I found highly invasive and also feeling very stupid and paranoid.

It is over now and weirdly, I think because the bank felt sorry for me, they offered me free concert tickets.

(I phoned them back on a different line to ensure that my phone hadn’t been hacked too. Weirdly speaking to the same call-centre person, which again led to a whole sequence of questioning… What were the odds…)

I know, a bizarre sequence of events.

What I think upset me the most was the consideration that I had been duped – what might have happened to someone without an internet-savvy son nearby? Even without losing money, the sense of invasion of my privacy was horrible;

Made worse I think because the conversation was with another person, with what I thought to be a Yorkshire accent.

The bank later told me they could have been from anywhere in the world using accent creation software.

What next?

I suppose we have to muddle through, putting our faith into something.

And we wonder why the Right seem to triumph in elections;

It is fear and their supposed offer of certainty.

Give-up a little of our human rights and we will be safe.

All hard to accept.

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Inefficiency

Inefficiency is OK when it is unsystematic.

What I mean, is, imagine you are in a system and everything is in flux, pretty-much chaos – like the current state of the UK government.

Well, that is one thing.

It is explicable.

We are humans, we have neurology, personalities, self-interest, hormones, obsessions and all the rest; human all too human, type thing.

I can cope if someone bumps into my car because they are texting on their phone – they are being stupid, inattentive and irresponsible. You see, humans do these things; I will still be very angry, but, in the greater scheme of things it will make sense; round peg in round hole.

The other type of inefficiency is more insidious and there is a fine line between it and all the conspiracy theories that rock the youtube.

In its most overt form, you see people working to rule; this results in delays, congestion, disruption and ultimately collapse. Our society is based upon a flexible interpretation of the rules, with allowances made for the odd jay-walker or person breaking with social norms – perhaps, swearing in public or dropping litter; again, these are bad things but, we wouldn’t want people shot or incarcerated for these irresponsible acts.

Conspiracy theories are also used by powerful people to manipulate the innate human tendency towards fear, to worry that something might be wrong and take action that is mitigating or protecting; vote for the right-wing, say, this is an action that is based wholly in self-interest that is, fear.

Brexit – fear of immigrant hordes taking our jobs; a cynical trope, manipulated to incredible effect by some in authority.

No, no, my idea is far more insidious.

You ask for A, B or C, quite logical and straightforward and, for whatever reason it doesn’t happen; you excuse this as inherent systematic barriers, rules and regulations that affect everyone.

It is when you see that someone else, perhaps, calling A, B and C a different name, succeeds in their actions, that you begin to question.

When you want to recruit Jonas to an office job to support you and, for whatever reason Jonas doesn’t get the job; the advert, recruitment or workforce issues block the action.

Again, you accept that we are in a time of austerity, and, when the money is tight, resources are directed to where they are most needed.

What happens however, when you find that specific, meticulous, to-the-moment planning has happened and the world is transformed when you back is turned?

I’ll illustrate to make this more comprehensible.

Say, you walk through town and see shops here and there, in different stages of renovation, foreclosure or collapse – yes, the standard UK town high street in the current era.

Yet, between Monday and Tuesday one abandoned wreck is transformed into a gleaming, state of the art facility; I don’t know, maybe selling bagels.

You realise that in order for this bagel emporium to have appeared so suddenly there must have been planning, coordination and organisation; a different rule applies to this compared to all the other broken-down facilities you gave been walking past.

You see that the norm, the inefficiency that was accepted as just the way things are is actually an option, a choice and perhaps within the constraints of design, just as much as the new bagel shop. Let’s call it ‘Bagels R’ Us’.

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badersnatch book.pngI encountered this a few months ago after watching the Netflix short, ‘Bandersnatch’ – my son and I drove down to Birmingham to check-out the pop-up shop that appeared in the centre of town; It was the recreation of a 1980’s video-game newsagent of the type that I used to visit when a boy.

Just as with the decision-making TV show, there was amazing, meticulous planning. bandersnatch book.jpeg

It showed what we can do when we want to succeed and we share a common goal; in this case, recreating a sliver of 1983.

This is efficiency.

This might sound paranoid; I assure you it is not the case, it is a reality, that I will one day describe to you all. Just, not now.

So, sloppy, irresponsible, even, idiotic, I can accept, I see this as the human condition; like an apple falling from the tree. Engineered inefficiency, coordinated failure, that is another matter.

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office

What shall I call you?

Great blog from Zara on the topic of what we are called; funny – I was called ‘Rodney’ twice today and Rob once last week. It is a bit of a game, but, I think we matter less (in this context) than what we call our patients and what they call us. One of my favourite things is for nurses and other clinical staff feeling comfortable enough to call me Rod – it also helps make me not feel too old. 🙂

Zara’s Blog (the blog of a 40 something Primary Care Nurse)

This chapter is inspired by a thought provoking blog titled What would you like to be called? by Dr Rod Kersh https://wp.me/p6EWa3-23i and the recent conversations where student nurses have been referred to as “the student” even weeks into a placement.

When I was a student nurse back in the late 80s it was still quite common to be addressed by our surnames by some Sisters. I was never comfortable with this and on numerous occasions I failed to notice that they were referring to me. I often remarked that it was much easier and quicker to call me Zara than Student Nurse Read-Jackson. I always said, in an emergency, critical time would’ve passed before they’d said that mouthful! Most of my life I was simply Zara Jackson (I always imagined the name Zara Read-Jackson was more suited to some exotic, cultured lady rather than me, a down to earth kid…

View original post 588 more words

Value (WMTY)

When I was a lad, the concept of value was familiar.

It had, as far as I understood at the time, something to do with supermarkets.

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For whatever reason, the advert from Asda with a mum slapping the back-pocket of her jeans stands-out; perhaps this says more about me and my TV viewing than my burgeoning sense of value, but, nevertheless, I interpreted it in economic terms – good stuff for less; that kind of thing.

Nowadays value seems to be a word I use more frequently in relation to approach. How I see the world, how others see me, that kind of thing.

We share common values, being a shorthand for, ‘We think alike, we vote alike, we see the world from a similar perspective.’

It isn’t as stark as left and right, as, previously described, the world is (and has probably always) been too complex to split into two groups, yin or yang; despite the, and you know where this is coming from, the frustrating manner in which the UK is split between everything to do with Brexit (although some folk believe that the people aren’t split it is political ideology.)

Getting back to value.

What I see as right or wrong, as worth investing time and effort or disregarding; person ‘A’ might believe a big car, another, giving to charity and yet another, seeing as much of the world as possible in a constrained existence.

What matters to you?

This is key.

When we apply it to working in health and social care, doors unlock, we discover we are appealing not necessarily to our prejudices and preconceptions, but what is of importance to our patients and clients.

I don’t mind if you wear a uniform, have your hair up or down, are a little late or early, so long as you smile;

Others will care less about the smile and focus on the quality of the dressing, the details of the assessment.

Holistic Practice determines that everything is important, or at least, quality suggests we should arrive on time, with smart uniform, and conduct the best assessment as is possible given constraints of time and knowledge.

It becomes complicated.

I cannot understand the mindset of the Conspiracy Theorists, or, rather, I can understand, but don’t know why they can’t see the other side. I just don’t get it why anyone would want to vote Leave when Remain is so consistent with the trajectory of the Global Economy;

Heck, John Donne got it in 500 years ago; what haven’t we learned?

Maybe Earth is flat?

Maybe the Jews are conspiring to control the planet, extort the poor?

I guess when such uncertainties exist, when there is so much conflicting and overwhelming evidence of what is and what is not, you have to start somewhere; values seem reasonable.

What matters to you?

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Conspiracy

The rich conspired against the electorate to create Brexit, which will disenfranchise the poor to make the rich richer.

The earth is flat.

Aliens have walked amongst us since 1965.

Pick your crazy story and there will be a conspiracy associated.

This was brought starkly to my attention having listened yesterday to This American Life’s recent episode – Beware the Jabberwock.

The focus of the podcast is the emotional fallout related to the Sandy Hook Massacre in 2012.

Immediately following the tragedy, when 26 children and teachers were killed at an elementary school in Connecticut, theories began circulating on the web suggesting that it was a hoax; that no children had been murdered; the Left-wing Obama-influenced anti-gun lobby had conspired with Hollywood to create a make-believe scene to influence the electorate.

Crazy.

Obscene.

Devastatingly to Lenny Pozner whose son, Noah was murdered that day.

Trolls, hoaxers, psychopaths and self-publicists chose to circulate images of murdered children, all deteriorating into a bitter game of recrimination and hatred.

As I have recently written, the human brain is divided.

Left and right; whole or part. Creative or concrete; is it a wonder that Brexit splits the nation, that given the choice, humans seem to self-select into one or other extreme?

All things being equal I am here or there. I empathise with the lost, weak and defenceless or I consider their inadequacy, inefficiency as a blot on the landscape.

Possessing the ability to view the world through the eyes of another is a talent unique to humans; believing that it is ‘my way or the highway,’ is a backwards position.

The Trolls, the Alex Joneses (Not the wonderful Welshwoman) of this world are driven by an enthusiasm for success that many of us cannot imagine; it isn’t the winning, rather the taking part. Every man for himself, women and children first; sacrifice or sacrificial.

The outcome of the podcast was salutary; you can’t change the way people think. Left is left and east, east;

Similar topics have been covered before by TAL – I remember one where people spent time trying to convince Pro-Life protestors of the necessity for access to legal abortion;

The world is not black and white; nowhere is there absolute right, or all right or all wrong. Everything is shades, hues, indeterminate shapes and figures, the edges blur the further away you are from the object – this is reality. Nothing can remain in focus forever.

Accept that this is the way it is, that humanity is flawed no matter where you look and realise that we can only hope to arrive at truth or reality if we lower our guard and collaborate, accept one another’s inadequacy or inefficiency.

Sandy Hook; I can’t imagine anything worse.

Please follow this link and listen.

Beware the Jabberwock.

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Money

I have just finished reading Yuval Noah Harari’s mini-book, Money; published by Vintage and at only £3.50 I think it is a bargain.

No. it’s not about the cost of the book or the price of things, it is excerpts for YNH’s other two bigger books Sapiens and Homo Deus.

Anyway.

Those who know me know that I am no economist.

Sure, I am interested (a previous fan of Freakinomics), but, understanding the ins and outs of economies, finance and so on is beyond my ken.

The Global Financial Crisis was something about people defaulting on loans and bank bail-outs.

Now, some of you reading this will already understand what the bank bail-outs were; why and what.

To be honest, I never got it.

There is that scene in Mary Poppins where there is a run on the father’s bank; it was only after reading Money that I grasped what was going-on; I mean, so what if everyone wants to take their money out of the bank – it’s theirs is it not?

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Here is the example that YNH gave which I will change a little by using my own characters;

Roger Clydesdale is a bank owner.

Bob Moriarty is a builder.

Hannah Bun is a chef.

Now.

Moriarty has been working hard and he earns £1 Million Pounds.

He deposits this in Clydesdale’s bank.

Clydesdale now has £1 million in his bank, all of which belongs to Moriarty.

Everyone is happy.

Hannah Bun decides that she would like to open a restaurant in Clydesdale and Moriarty’s town; let’s call it, Sunnyvale.

Hannah Bun needs someone to build the restaurant – she doesn’t have enough cash, and, Moriarty the builder has offered to build this for her for £1 million.

Bun decides to ask Clydesdale for a loan of £1 million.

Clydesdale agrees that Sunnyvale needs a restaurant and approves the loan. The £1 million in the bank goes into Hannah’s account, who then transfers it to Moriarty’s.

Now.

Moriarty has £2 Million in his account; Clydesdale still only has £1 Million in the vault and Bun is hoping for a nice new restaurant.

Six-months into the project, the construction has encountered unexpected delays – asbestos; an unusually cold winter – frozen pipes, this sort of thing.

Moriarty realises that to complete the job he will need another £1 Million.

Bun decides that rather than go bankrupt and not have a restaurant, she will ask Clydesdale to loan her some more money.

Clydesdale sees that if he says no, he will have a problem as Bun won’t be able to repay the money and Moriarty will be unhappy as the £2 million, he thinks he has is only £1 Million. So, Clydesdale agrees the loan and gives Bun another million, which she passes to Moriarty.

Moriarty now has £3 million in the bank (or so he thinks, give or take what it has cost him already to live and do the work), Clydesdale still only has £1 million in the vault and Bun has a half-built restaurant.

This can go on, Yuval informs us up to ten times, so that Moriarty can have a theoretical £10 million in his account when Clydesdale still only has Moriarty’s £1 million in the vault.

Now, it is likely during this time Clydesdale will have been speculating, trying to find ways to make Rodger’s money bigger – investing in all sorts of other ventures that he hopes will pay a better return. (Home mortgages are always a sound investment).

It all goes pear-shaped when either Moriarty wants all his money – this I think is a ‘run on the bank’ or Bun decides she can’t cope with such debts and runs away, that is, ‘defaults on the loan’.  poppins run on the bank.jpeg

Now Moriarty wants his money and he hasn’t done anything wrong, other than perhaps charge a lot for a restaurant that is only worth £500,000, but again, that is another story.

Unless something gives it will be a horrible mess.

Clydesdale will be broke, Moriarty will be broke (he has also probably done other theoretical things with his pot of money) and Hannah, well, she might have skipped the country.

The bank bail-out was the government stepping-in and giving Clydesdale the £10 million that he owed to Moriarty, this money of course belonging to the citizens of Sunnyvale.

And, so it goes.

I guess, this is why economists, hedge fund managers, bankers and others get to earn so much money – it is a very complicated business that not everyone can understand and, when you add artificial intelligence to the mix, that is, computers working out clever ways to dice and parse the money, well, heaven knows.

I hope I have fairly represented this section of a little book which is part of a bigger book.

As I say, I’m a doctor who likes to talk with people about what is wrong or right in their lives, not a money mastermind.

Any errors are mine; please don’t use the contents of this blog to invest money or decide to build a restaurant.

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If you want to read my other blog about Yuval, follow this link.

Or my blog that mentions Freakinomics.

NHS Assembly, The Health Foundation and being an Outsider.

I don’t know if writing this will send me more into the periphery of health and social care – if so, bring it on!

It is a story of where I am, what happens around me and how I feel about it.

All of this is a representation of my own feeling and experience.

It just is.

This story began a few of years ago;

The Health Foundation, which is a huge national organisation overseeing health improvements and evaluation in the UK launched something called ‘Q’ – looking-back through my emails, this began in 2015.

Q was intended to be a UK version of the IHI – the US’s Institute for Healthcare Improvement originally overseen by my hero Don Berwick, which has an aim to improve effectiveness, reduce harm and save lives in healthcare.

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I duly applied and wasn’t successful; not selected to be part of the ‘founding cohort’ – fair enough; I accepted this reality and moved-on; following my own path.

There was a second round of application in 2016 – again I didn’t meet the grade and so went back to whatever I was doing.

Finally, in September 2018 they opened the doors to everyone, and I was allowed in. I received my little red badge and fin.

The thing is, by that point the original passion for joining that I had shown back in 2015, as what you might call an ‘early adopter’ had waned and really, I saw that I had done lots of things – improvements in quality without their help.

The same thing has happened to me with the NHS Assembly; again, when I speak to most colleagues, they haven’t heard about it – it is the body forming to enact the NHS Long-Term Plan. Many of the aspirations are fantastic and aligned with what I see as the way ahead for care in the UK.

I applied, but was again unsuccessful in joining.

Indeed, when I look back, I see several events that have shaped my future which pivoted on either unsuccessful application or interview. If you want to see proof, you can look back to my blog here.

What I know about myself is that I am a passionate quality improver – that is, interested in making things better, more efficient, person-centred, compassionate within health and social care and mostly when I get the opportunity to do things (i.e. I am not held-back by too many strings), things work and care improves.

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Yet, I seem to have a problem with applications and interviews.

I shouldn’t take these too much to heart; perhaps accepting Groucho Marx’s belief that he wouldn’t want to be a member of any club who would let him join.

I think equally of Colin Wilson – he was a hero of mine when I was growing-up.

In the 50’s Wilson wrote a ground-breaking work of philosophy and reflection called ‘The Outsider’ (If you haven’t read, I highly recommend) – Colin wrote this whilst sleeping in a tent on Hampstead Heath and spending his days in the British Library.

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He talked about Outsiders in history, art and literature – Sartre, van Gogh, Dostoyevsky, Camus – all guys who I suspect wouldn’t have done too well at interview, not that I am specifically comparing myself with them, just, I can understand the problem.

At the centre of this however is peer-support.

It is hard to be an Outsider.

It is hard to go it alone.

We humans aren’t designed for prolonged battles of isolation;

How do you reconcile this Outsider stance and frequently not being allowed-in with a desire to make things better, with finding a way to sustain momentum?

Society’s existence follows a set of rules that are hidden to some, and it is likely those who can’t quite see the where’s and what’s who sit on the outside; they don’t see what is before them as they are captivated by something else.

I don’t hold a grudge against these various organisations; it is just the way it is and probably, like most parties, if you aren’t invited it is best not to attend.

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