The challenges ahead

With little surprise to myself, the government has quietly fudged on the key recommendations of the Francis Report. Despite the detailed report commissioned at no small expense by this government, they have compromised on the recommendation of candour to be shown by any NHS staff who witness ill treatment or neglect of patients. Some would argue this is a betrayal of the very report which they ordered and a betrayal more pertinently of the public who have to brave treatment therein. It is my contention that the government has made an indirect concession that such a requirement is not realistic. They appear to concede that it is not within the basic make up of all employees serving the second largest employer in the world, to actually care. This could be viewed as an indictment on the NHS but I prefer to see it as a realistic view. To care for another person is felt - not taught or demanded. This is why I was so interested to see what would actually happen in the aftermath of the Francis Report.

Let me be abundantly clear. Lord Francis has done a great job in dissecting with forensic detail the chapter and verse of the catalogue of error unearthed at Stafford. We have to be realistic though. Just as Marx and Engels espoused a society in which we would all co-exist in Utopian bliss content with less, with wealth more evenly shared out, Francis is the proponent of a very idealised NHS in which neglect is unacceptable. Of course, in an ideal world, he is quite right to aspire to such an organisation. Sadly, we are in a real world.

I once read a joke book which described a bureaucracy as an enormous cess-pit where the really big bits float to the top. How true. The problem is an old one. Greed and history tell us that protecting a high paid job is often far more important than justifying it. The essence of the problems affecting Stafford and a whole host of hospitals elsewhere is accountability. Many will point to staff shortages resulting in fewer staff being asked to do yet more in their already stretched roles. This rather misses the point though. Caring for another man or woman is not necessarily complicated. Many of the faults identified in the report concerned very basic issues which would have been dealt with had a basic standard of care been in situ. There were of course no shortages of managers. Management is essential of course - in moderation. Management, by definition, is only ever as good as its remit. Introducing so many targets whose main requirement was to save money was always dangerous. Money.

We don't need to enter into the world of complex mathematics to get an idea of the problems besetting the NHS. There is a finite pot of money. More is being taken out of this pot than is being put into it. Therein lies the problem. Ergo, how do you take out less to try and re-dress the balance? Simple. Less people going to hospital means less strain on the system and the much fabled pot of money. In my years thus far as a medical student, certain hospital disciplines are obviously at a dangerous level of strain. Keeping it simple, sugar, alcohol, tobacco and a basic lack of exercise are conspiring to present the health profession with the unenviable task of prolonging life at no small cost. All of these factors to a lesser or greater extent are addictive. It is very difficult to change the ways of a man who goes nightly to his local pub for three pints and a few cigarettes on the way home. It is not so difficult to educate the next generation. Much has been achieved already in this direction but much remains to be done.

As I write, a handful of supermarkets will have just enjoyed another week of massive turnover in respect of a religious festival whose relevance recedes by the year. Mountains of chocolate and obscene quantities of food high in carbohydrate will have been washed down with huge vats of cheap booze and all the while the supermarkets get richer and the NHS poorer. Within the privacy of their own homes, people are only accountable to themselves for their consumption. In the pub, such habits are subject to a lot more scrutiny and no bad thing. Pubs go to the wall at an alarming rate and many become scaled down versions of the large supermarkets. This has been one of the biggest scandals of recent years for which every government since Thatcher has played its part. Pubs once played key roles as community hubs were people got together socially with the aim of inebriation a long way down their list. The pubs though have been competing on an unfair playing field for a long time now. How can a pub hope to compete with the loss leader booze deals of the supermarkets? On many levels, minimum pricing for alcohol is no longer optional from a moral standpoint. Morals though do not seem to attract the attention of this government. Minimum pricing would give a much needed lifeline to a pub sector on its knees after years of supermarket dominance. It would also provide a greater deterrent to those who over-indulge and a greater revenue to the NHS so badly in need of it. Put simply, now is the time to be bringing people closer together rather than driving them further apart.

I took my son to church this morning and was very pleased to see so many other children there too. On this day of all days, there has to be hope for the future and the future is in their hands. First though, it is the moral duty of my generation to put them on a path which has apparently eluded so many since the second world war. If the NHS is indeed to remain free at the point of access according to the founding principles of Bevan, each and every one of us needs to wake up and take stock. I pray we do. Caring is what an army of carers do daily for loved ones the length and breadth of the land. Having been a carer myself, I can assure anyone, you wouldn't do it for the money. If every carer decided tomorrow that they no longer wished to do so, the NHS would be bankrupt within the hour. The debt we owe these people can never be repaid. They are the silent majority without whom we'd all be in trouble. They are also the role models for a new generation who ought to be at the forefront of thinking for the new NHS. Managers they are not. Real people with compassion and feelings they are. It is a great pity that some of the patients in Stafford weren't in the hands of real carers who get on quietly with the job in hand every day in their communities. I would further venture that community holds the key to future healthcare.

The recent spate of closures of community hospitals in North Wales beggars belief. Here, the ethos seems to propose putting even more strain on the general hospitals rather than relieving them. This is utter madness and history will show the folly of this decision. The bigger something gets, the more its essence is lost and we need only peruse the history books to witness it.             

Denied!

I woke today with news that my route to Shrewsbury was blocked at the Nant Y Garth Pass and, it seems, all routes thereafter. I have thus been denied the chance to attend my weekly dose of "Keele Spine". This is an obligatory session whereby 50 fourth year medical students based at Shrewsbury are shepherded into a small classroom to receive a lecture on a clinical subject area. This experience varies between fascinating (sadly rare) and dull (sadly common) and heralds the weekend with 50 medical students in a semi-comatose state. I was thinking of my colleagues today wondering how their two hour talk on pain went. I also wondered whether they were in empathy with the subject matter and look forward very much to finding out all about it on Monday. Toodle pip!  

A Handful of dust

As of March 2011, the UK was estimated to have spent approximately 9.2 billion pounds on its involvement in the Iraq war. Up until now, no legitimate reason has ever been justified for our involvement and yet as recently as yesterday, Tony Blair was still insisting he had no alternative. We now know that there were no weapons of mass destruction. There is oil though. Up until now, the UK has spent 18 billion pounds on the war in Afghanistan and is now resigned to leaving having effected no change to that country as universally predicted by everybody with a modicum of common sense. George Osborne today delivered his budget in which annual borrowing was predicted to remain at about 121 billion pounds.

Next year will mark the centenary of an event which took place in Sarajevo in Serbia. The assassination of Archduke Franz Ferdinand II and his wife by Gavrilo Princip, a nationalist in favour of a separate Yugoslavia, was to have consequences which would exert a monstrous effect on the whole of Europe and far beyond. It is widely agreed that human life has seldom been wasted on such an obscene scale. Every year, Armistice Day is observed to remember those who fell in the war which would never be repeated. History, it seems, is often read but seldom learned from.

As I write, it is widely predicted that the UK will shortly become involved in the conflict in Syria where thousands die by the day at the behest of yet another despotic dictator. Iraq is now far from being a safe country which brings into question the legitimacy of our involvement. The new Pope is on record as saying that the Falkland Islands ought to be returned to Argentine sovereignty so I wonder how long it will be before we return to flex our jingoistic muscles in the South Atlantic?

I saw today that yet another Public Service (surely one of the greatest oxymorons of all time?) has decided to stage a one day strike in protest against pay, pensions and working conditions. Note the order there. Pay first, pension second and working conditions third. It is little wonder that public finances are in such an absolute mess when public service has become anything but. If the estimated 2.5 million unemployed in this country went on strike tomorrow, I wonder what they would be protesting about? No food? Fuel poverty? No hope? No job? Its a job to know where to start really.

Doubtless, we will all make a big thing of remembering the Great War on the centenary of its beginning next year. But I wonder how many of those killed would feel if they could see the Mother country now? Perhaps we could strive to give them something to reflect the sacrifice they made for us. Maybe we could all start to make do with a little less and be grateful for the important things. Maybe we could refrain from being involved in any more war. Maybe.
     

A clean slate

Yesterday two men embarked on their respective tenures each as the leader of over a billion people. 59 year old Xi Jinping was yesterday appointed president of China with only one of the 3,000 people involved in the voting process not voting for him. His job is for ten years and will not be without its challenges. He is faced with sustaining an economic growth rate which remains alien to just about every other country in the developed world. His country has a record on Human Rights about which the less said the better. China has an economy rooted deeply in fossil fuels and steel. On the back of its unparalleled growth over the last three decades, it is also enormously cash rich which immediately sets it apart from most other countries. China still refers to itself as a communist country but actually appears to be less so with the passage of every year as the ivy-like grip of capitalism slowly takes hold. For all that, it remains the one country with any chance of bringing to order North Korea whose actions seem ever more ominous based on the events of the last few years. Whether China is still boasting annual growth rates in excess of 5 per cent ten years hence is open to conjecture but I fail to see how. As all children know only too well, even very large bubbles burst in the end.

At the tender age of 76, Pope Francis yesterday embarked on his papacy following the deciding vote of the college of cardinals. Hailing from the Argentine, he is in fact of Italian descent so should feel quite at home in the Vatican. His succession follows the surprise resignation last month of Pope Benedict who will doubtless now lurk in the shadows. While many expressed surprise at his resignation, it was entirely understandable when you stop to consider the enormity of the task with which he was faced. Granted, the Catholic Church continues to grow in the impoverished continents of Africa and South America. The problem though is elsewhere. Although he must now confront the growing issue of contraception in the face of HIV and a whole raft of other sexually transmitted diseases, his real challenge is to somehow engage his church once more with its traditional heartland of Europe. As commercialism and materialism have assumed the ascendency in recent times, the Catholic Church by contrast has receded. Allegations of child sexual abuse have come at the worst possible time and must be addressed. While the Eastern religions continue to grow, congregations within the church have become old and decrepid with little new wood growing through. It is little wonder when the church refuses to budge rather like a child playing musical chairs. The music has re-started but the church remains seated. When it learns to get up and join in, so too will the people. It is little coincidence that the fibrant evangelism of Africa boasts a healthy growing church whereas the staid, medieval church in Europe experiences the opposite. Pope Francis has made a good first impression but, like St. Francis Xavier, he will ultimately be judged more on his deeds than his words.

Ten years hence I wonder whose legacy will be the more noteworthy: Pope Francis the spiritual leader or Xi Jinping the leader of China. Either way, they both have a big job ahead of them and whether aged 59 or 76, it would test the devil himself. You can please some of the people some of the time.....   

Under promise and over deliver!

During the years I spent within the Sales industry, certain mantras were repeated over and over again. Some could be regarded as cliches but contained a great deal of wisdom for all that. One example was the observation that we have two eyes, two ears and one mouth. The trick was to try and employ them in the same proportions. Another was more of a truism. I was constantly being encouraged to under promise and over deliver. Broadly speaking, this means that you refrain from over-committing yourself to any agreements with customers lest you be unable to honour them. The supposition followed that the customer was never let down and constantly satisfied that promises were duly kept - albeit promises often with the substance of tissue paper. To a point this approach sustained many a business relationship.

It was with a great deal of interest that I read recently the conclusions of the inquiry in to the events at Stafford hospital which resulted in so much harm and suffering. Health Education England which does not yet exist has promised that future medical students will be recruited based on their compassion. Henceforth, universities will be required to recruit medical students based on their values and behaviours. So far so good. For those of you who have followed this blog, you will be familiar with my views on this. It was my wish to undertake research into this area last year but I was sadly if predictably rebuffed by my medical school. It was deemed more important for me to pursue research in a more scientific area. To tick the box, I treated their approach with the contempt it deserved and studied the psycho-social aspects of being the recipient of a renal transplant. I thus studied an area about which I already knew rather a lot while at the same time being involved in an overtly non-scientific area. But enough about my relationship with the medical school to which I am currently affiliated. I make a broader point here. It is my view that the feelings of patients are as important (if not more important) than the science underpinning the clinical decisions being made about them. It is one thing to qualify as a doctor with an encyclopaedic knowledge of the textbooks which you have studied for the past few years. It is quite another to connect with the person in front of you with basic humanity and understanding.

I made the assertion this time last year that empathy is the result of many factors. Our upbringing is hugely important as are the life experiences to which we are exposed. You can teach a wide variety of subjects but empathy is not one of them. I have seen doctors in hospitals whose empathy I would deem insufficient to attend to an animal. It is all very well claiming that medical students will now be assessed based on their values and behaviours but I wait with baited breath to see how they propose to achieve this. I just can't see how you can gauge or measure such qualities. My fear is that a separate multiple choice paper will evolve along similar lines to the current situational judgement test being used to determine foundation year allocations. The only problem here is that a new mini industry will spring up whereby companies will offer advice in to how to achieve higher marks. From an altruistic standpoint, I think I understand the words of Health Education England. What I don't understand is quite how they propose to achieve this. Put simply, they can't.

If they refer back to the work of Carl Rogers in 1951 they will begin to form a more clear appreciation of what empathy is. For the record, Rogers' seminal work remains the key work in this field and has been referenced over the years to within an inch of its life. Rogers asserted that for a person to grow, they need an environment which provides them with genuineness, acceptance and empathy. Genuineness arises from openness and self-disclosure. Acceptance stems from being treated with unconditional positive regard. Empathy results from being listened to and understood. Only when this trio were established could self actualisation take place. Furthermore, we behave as we do because of the way we perceive our situation.Rogers believed people to be inherently good and creative. They only become destructive when a poor self-concept or external constraints over-ride the valuing process.

Carl Rogers (1902-1987) was a humanistic psychologist agreed with most of what Maslow believed, but added that for a person to "grow", they need an environment that provides them with genuineness (openness and self-disclosure), acceptance (being seen with unconditional positive regard), and empathy (being listened to and understood).
Without these, relationships and healthy personalities will not develop as they should, much like a tree will not grow without sunlight and water.
Rogers believed that every person can achieve their goals, wishes and desires in life. When, or rather if they did so, self actualization took place
- See more at: http://www.simplypsychology.org/carl-rogers.html#sthash.4QpYZ7ru.dpuf

Carl Rogers (1902-1987) was a humanistic psychologist agreed with most of what Maslow believed, but added that for a person to "grow", they need an environment that provides them with genuineness (openness and self-disclosure), acceptance (being seen with unconditional positive regard), and empathy (being listened to and understood).
Without these, relationships and healthy personalities will not develop as they should, much like a tree will not grow without sunlight and water.
Rogers believed that every person can achieve their goals, wishes and desires in life. When, or rather if they did so, self actualization took place
- See more at: http://www.simplypsychology.org/carl-rogers.html#sthash.4QpYZ7ru.dpuf

The problem with Health Education England is that they have over promised on a subject area in which they appear painfully lacking in knowledge. The only possible outcome of such a knee-jerk response is under delivery. As it stands, medical students are coached liberally leading up to their interviews to gain entry. The real challenge is this: How do you get the true measure of the human being sitting in front of you? Not the bright student who studies hard and achieves straight A grades. Not the well presented and well dressed person with the well rehearsed answers. Not the person who sounds more like one of those Miss World contestants who claims all sorts of nonsense. What you really want to know is how they would instinctively react if an 85 year old gentleman lying in a bed couldn't reach his drink or his food. I wish Health Education England well and hope they have a trick up their sleeve which has thus far eluded me.