- In November, my friend Sally took me to The Church of St Mary the Virgin, Putney and reminded me about The Levellers. As she read aloud from Thomas Rainsborough’s famous quote, I felt a shiver. “For really I think that the poorest he that is in England hath a life to live, as the greatest he.“ After this terrible year, surely we can remember this, and act accordingly?
- History shows that, when times are hard, false prophets can persuade those who are suffering to blame the “other” rather than the ones who are the true source of their misery. And cause them to use their precious vote in ways that challenge more liberal values. But if we merely condemn such choices, we have no hope of turning the ugly tide lapping our shores. After the results of Brexit and the US presidency, I have come to realise that we need to judge less and listen much more so that we can understand why people are so angry with the established order.
- This year we lost far too many extraordinary people, including the wonderful Jo Cox MP. She wasn’t afraid to work with those on the opposite side of the political divide nor to challenge orthodox views. I have concluded that members of political parties who spend all their time arguing or blaming one another rather than seeking common cause, as Jo did, are a major part of why so many are mistrustful of politicians.
- This month, the government announced that, as a society, we are not doing enough to prevent suicide. And that there will be league tables published soon to show which areas are lagging most. As one who devotes time to volunteer in suicide prevention, I find this extraordinary. We can do a great deal to reduce the incidence of suicide by tackling stigma, offering education and training and supporting voluntary services such as the Samaritans. But ignoring the main reasons for the rise in the rate of suicide is dishonest. Benefit sanctions, fitness to work assessments and cuts in social care support are causing hunger, homelessness, and shame from being a burden amongst the most vulnerable of our fellow citizens. And for a growing number, the only options at night are a tent, a homeless shelter or a shop doorway. No wonder that life feels increasingly unbearable to some.
- And while the government congratulates itself on low rates of unemployment, zero hours contracts and minimum wages are directly causing the rise in reliance on food banks, payday loans and other expensive credit. It is not refugees or so-called benefit scroungers we need to fear. It is people who “create value” (what a meaningless and loathsome phrase) from the misery of others. The Mike Ashleys and Philip Greens of this world. And the Rupert Murdochs and Paul Dacres who would have us believe that fear of the other, rather than compassion for our fellow citizens, is what should drive us. But I realise that grumbling to those who already agree with me is not enough. I’m going to do better in 2017.
- I have been learning how to apply the Myers Briggs Type Indicator (MBTI) to use in my practice as a coach. I could bore for Europe on this subject, but suffice to say, it has been a revelation. And the greatest insight of all has been finally appreciating at a very personal level what Carl Rogers meant in 1961 when he said: “What I am is good enough, if I would only be it openly.”
- I have also been learning how to be a Samaritan. I will be writing more about this next year. All I need say for now is that I gain as least as much as I give, and that the training and support for volunteers is absolutely wonderful. And with all that I mention above, and at this time of year, Samaritans are needed more than ever.
- This year, we lost so many wonderful people, including Twitter friends @GrangerKate and @GraceAndGloryDan. I would like to thank Zoe, courageous mother of Adam Bojelian. Adam sadly died last year. And Zoe reminded me that people who are bereaved value nothing more than being given the kindness of time to talk about the person they have lost.
- Finally, I have learned that people like pictures of cats. So here is William, my personal pet therapist, to wish you peace at Christmas. And may those who are lost, lonely or grieving find kindness among strangers as well as friends.
Last week I was introduced by Dr Kathy McLean, Medical Director at NHS Improvement to 180 people comprising senior NHS clinicians, managers, directors, chief executives, patient representatives and members of staff at NHS Improvement, including most of their executive team. And I wondered how my homespun talk about improvement, leadership, the universe and everything would go down.
As it turned out, quite well.
The cartoon above was drawn by Inky Thinking. I don’t know how they do it, but they capture everything you say that you want people to remember.
Here is a word-based precis:
- If you forget that culture always trumps strategy, your efforts to improve services will be ineffective. I’ve been there and occasionally done it the right way. But more often the wrong way.
- You can’t help others to improve unless you are OK yourself. I have form on not remembering this.
- Leadership in public services has never been harder with our 24/7 media, including social media, and the anti-public sector rhetoric that appears in most newspapers.
- Plus we live in a post-fact world – see this article by Guardian Editor-In-Chief Katherine Viner. People believe things that are not true, and don’t believe things that are. I’ve had personal experience of this. And it is horrible.
- Being an NHS leader is very lonely. Never more so than when you are awake at 3am. People get in touch to congratulate you when something goes well. But when things go wrong, people you thought were friends seem to melt away.
- There is never enough time to think when you are running NHS services because of competing demands, often from those who are meant to be there to help you make improvements. But you must create time to think or you will make bad decisions.
- Filling senior vacancies in the NHS is getting harder. And we should worry about this. Because if we aren’t careful, the only ones who apply to be in the firing line will be those who don’t care what others think about them. And that would be very bad for all of us.
- We cannot separate leadership from mental health. In my opinion, people who experience mental illness from time to time can make exceptional leaders. It is only one thing about them. Plus, they develop skills through therapy that are invaluable – such as managing their own mood, listening really carefully, and not making assumptions about others.
- I have experienced depression off and on since the age of 15. A nurse said something damaging to me when I was 22 and vulnerable which I absorbed deep into my psyche. For the next 36 years I stigmatised myself, despite being an active campaigner against the stigma of mental illness. It was when I finally came out about my experiences that I was able to address my self-stigma. I have made many friends since then. But if only I had done it before, I could have been a better, more authentic leader.
- Mental illness messes with your head. It affects 1:4 of us. But 4:4 of us should care about it, not just on humanitarian and economic grounds, but because almost everyone can be affected. We are all on a spectrum of resilience, and if enough bad things happen to us, especially at a young age, most of us will experience post traumatic damage.
- When I appeared suddenly to get ill with an acute onset of depression in 2013, it was a culmination of things. My own susceptibility, but also workload, loneliness, weariness as I approached retirement, not taking care of myself, listening too hard to my own negative voices, and putting a lot of energy into maintaining a positive front. It wasn’t caused by internet trolls. But they didn’t help.
- So please don’t do what I did. Get to know yourself. Talk to yourself honestly about how you are. Talk to your loved ones. Take care. Be the best version of you, but make sure that it is you. And try always to see yourself as an improvement project – this makes it easier to accept criticism without it cutting you to your core. I’ve only learned this in the last few years, and it is a revelation!
- I am lucky. I have dear family and friends. And I got great care. I was able to go back to a job that I loved, which was a major part of my recovery. I know it isn’t the same for everyone.
- Since the summer of 2014 when I finally hung up my chief executive boots, I’ve been helping others in various ways to be the best version of themselves. And I’ve written a book which I hope you will read when it is published later this year.
As I finish this blog, I think of someone who embodies improvement in everything she does. The talented, compassionate and extremely resourceful Dr Kate Granger. Kate is currently in a hospice in what are probably the final stages of a rare and awful form of cancer. But as well as sharing the intimacies of her progress through terminal illness via her wonderful talks and social media, Kate has also revolutionised the NHS and other healthcare systems around the world with her #HelloMyNameIs campaign. She has written several books, and completed amazing things on her bucket list. And not content with that, Kate and her husband Chris Pointon are urging people to make donations to the Yorkshire Cancer Centre, a small charity that helps improve the quality of life of people living with cancer. You can donate here.
Kate and Chris demonstrate that being a leader isn’t a job, it is an attitude of mind. That anyone can make a difference if they focus on something that matters, turn a great idea into an innovation and build support for it through honest endeavour. We can all learn about improvement from them.
May you go well, both of you.
25 July 2016 postscript:
Chris has just posted on Twitter that his wonderful wife died yesterday peacefully in the arms of her family.
I only met Kate once. I will never forget her. She had an extraordinary stillness and presence. I hope the knowledge of the difference she has made and will continue to make for many years to come will sustain Chris and all who loved her in the difficult times ahead.
My heart goes out to all of you. May her lovely soul rest in peace.
There are five stages to grief, as explained by Kubler Ross.
- acceptance (sometimes called accommodation)
We do not progress through the stages in a linear fashion. Some may have to be repeated. If we are not careful, we can get stuck at any of the first four, and never fully achieve the final one, of acceptance.
Today, those of us who voted Remain are feeling some or all of the first four stages. Only a few have reached the fifth by now. Some never will.
We have a right to feel angry. The referendum was unnecessary. Some time ago, David Cameron made a promise to appease certain members of his own party. He probably never expected to have to keep it.
After the result, the only honourable thing he could do was resign. As he did so, he was trying hard to appear to have achieved acceptance. But the catch in his voice gave the game away.
And he may never achieve it. Political careers in high office almost always end in failure. But this is failure of a most awful kind. Perhaps we can be kinder if our current Prime Minister shows statesmanship over the coming weeks and begins to chart the way through unprecedented choppy waters.
The reason many voted Leave was not about immigration or perceived European bureaucracy. It was a protest vote against the greed of big business, the banking crisis which has affected poor and vulnerable people much more than those who caused it, and a political ruling class that seems dangerously out of touch.
Can we listen really carefully to those who feel this way? We need to heed their voices, as well as the cries of anguish from those who voted Remain. And listen to both groups above the triumphal clamour of the minority who believe we have “got our country back”.
It is going to be very hard. Once hatred has been unleashed, it is hard to put it back in its cage. The rise of far right politicians and alliances are real and present dangers.
The size of turnout demonstrates that when people feel their vote will count, they are more likely to use it. So maybe we have to rethink our position on our current electoral system that disenfranchises so many.
And perhaps those towards the centre or on the left politically, if indeed such definitions are even valid in this context, can stop fighting one another and think about what matters? And who our real enemies are?
In the early stages of grief, it is important not to make momentous decisions. Words or acts of anger, hatred and blame will not help us.
So let’s hold on. Let’s be kind, to ourselves and to others. We are beaten. But we are not broken.
Yours, in solidarity with the human race
This time last year, I wrote a blog for newbies going to the NHS Confederation Conference. I decided to do an update for #Confed2016.
These are my top ten tips for having a fruitful time. By the way, you don’t have to be going to Manchester to make use of it 😉
- Don’t try to see and do everything. Be choosy. Treat the conference like a festival. By all means tweet about what you hear. But do also give the events you choose to attend your undivided attention.
- If you only seek out sessions and speakers to confirm your views, you will waste time and money. Arrive with an open mind. Ask questions. And be prepared to learn new things and to unlearn old ones.
- Some people need no encouragement to network. But if you aren’t confident about bounding up to someone you admire with an outstretched paw, don’t worry. Practice saying #HelloMyNameIs to people who look like you feel – perhaps a bit lost or lonely. And remember what Dale Carnegie said: You can make more friends in two months by becoming interested in other people than you can in two years trying to get other people interested in you.
- Dress for style AND comfort. These are not mutually exclusive.
- Never forget you are at work. Stay out late if you must. But if someone makes you an offer you feel you cannot refuse, say No. And mean it. What goes on at conference does NOT stay at conference.
- Take breaks. Go for a walk. Have a rest in your room. Do shopping or emails or visit the Lowrie. Drink coffee.
- At the same time, stay focused on why you are there. The NHS is in a bad way. It is not only being slowly starved of cash. Services are overwhelmed because current methods of doing things are unfit to meet the demands of so many people with multiple problems. We need leaders like you to find two or three changes that will make the most difference. And to devote their careers to making these things happen.
- Remember that innovation is as much about stopping things as starting them. That there are no quick fixes. And that culture eats strategy for breakfast*.
- You will meet folk having a hard time. Please don’t avoid them. Despite all the talk about compassion, our beloved NHS has become less compassionate. There is too much focus on inspection, compliance and performance. And insufficient attention paid to recovery, renewal and support. Please spend time with people working in very tough places. Listen if they seem angry or frightened. One day, this could be you.
- Take a look around you. Notice the top of the NHS. How very white and very male it is, despite the NHS workforce being 70% female and 20% BME. Ask yourself why this is so. And if you think it matters, do your bit to help to change it.
I’ve been to a few conferences. And been inspired. I hope you will be too. Have a wonderful time xxx
*This was never actually said by Peter Drucker or Edgar Schein, to both of whom it has been attributed. But it was what they meant. Sort-of.
With growing frustration, I watch how friends who are “experts by experience”* are increasingly being treated by the NHS and the various bodies tasked with inspecting and improving it. Such as being invited to be part of an inspection as an equal member of the team. But being paid many times less than anyone else, possibly even less than the living wage. Or being asked to join a group to produce guidelines or develop a new treatment or service change, bringing knowledge, skills and experiences that no-one else around the table can possibly have, for nothing or for a fee that is so close to nothing as to be insulting. Or being invited to speak at a conference but being told that “we have no budget for speakers” when clearly the conference is a commercial event AND the other speakers are being paid either by virtue of being in full time employment or a handsome fee.
I had an NHS career spanning 41 years, including 13 as a chief executive. My career as an expert by experience only began officially in 2013. But I have the benefit of an index-linked pension, which allows me to live well (although not as well as some might think because of decisions made when I was young and poor). Plus I can still earn money doing other things. So I can make choices about how I respond to people who invite me to speak at their events or otherwise draw on my experiences.
But many of my friends do not have that luxury. Opportunities to develop careers have been fractured by illness, disability and arcane, terrifying benefit rules which are themselves disabling. Their earning potential is therefore limited.
And my friends find that their generosity, goodwill and desire to help others is increasingly being abused. Despite rhetoric about patient centred care, co-production, peer-learning and a whole load of other worthy aspirations spouted by leaders in and around the NHS, those very same organisations are showing an increasing lack of respect and value for the only people who can truly help them achieve their improvement aims.
I’ve done it myself. Years ago, when I saw the size of the budget allocated to service user involvement on an important capital scheme, I knew it would be the first place I would have to go to make savings, should any be needed, despite it being a pittance compared with the professional fees being paid to architects, quantity surveyors, lawyers and the like. I did it, and at the time I rationalised it because I felt I had no choice. Looking back, I feel ashamed.
Why do we, as a society, place so little value on what matters most? Why do we pay the person who cares for our loved ones when they are dying barely enough to cover the rent on a pokey flat, whereas a man running some oil company gets £14 million a year? And why we do only see success in terms of earning potential, rather than the gifts a person brings to other humans and the planet?
I can’t change societal values. But I can make an impact on what we do in the NHS. I am lucky to have a voice. And I’m going to use it.
Wise managers understand this:
- If you can save money and achieve the same outcomes, that is a cost saving
- If you spend the same amount of money but do something better, that is a service improvement.
- If you spend more money to achieve a better outcome, that is a service development
- If you spend less money and achieve less, that is a service cut
- But if you spend less money and pretend you are doing it to make an improvement, that is usually a lie and a cop-out
So to the people who say that they’d love to pay experts by experience what they used to pay them, or even anything at all, it’s just that the money is really tight and it’s getting even tighter, I say this. Please think again. What else are you spending that public money entrusted to you on? What really matters to you? And if you must make draconian savings, why not try being as parsimonious with your auditors, your bank, your staffing agency, all your other contractors for professional services, your regulators. Even your directors and your staff.
And let’s see what happens.
And to my expert by experience friends I say this: we have something that the NHS should treasure, our personal intellectual property. Let’s continue to be generous and compassionate in how we share it.
But let us also expect respect.
*Post Script: I understand that the term “expert by experience” is of itself problematic. It implies that all the person brings is their experience of a condition and the treatment for that condition, rather than a much wider set of skills and attributes that, almost certainly, will bring richness and intelligence to the debate and from which those who work in the system will benefit in ways they had never envisaged. If, after conversations with wise people, I can work out something useful to say on this, I will. For now, I apologise about the paucity of the term.
Post Post Script: It is less than 48 hours since I posted this blog. It has been looked at 700 times, stimulated over 500 responses via Twitter, and comments such as the ones below. It seems that I have touched a nerve both for those affected by the things I have written about, and for those working in organisations that describe one thing in their values but seem to act in a different way. That was the purpose; there is no point blogging if there is no subsequent debate.
I am grateful to all of the commentators, but especially Alison Cameron @allyc375 who helped me over the terminology and with whom I am hopefully going to be doing a double act soon on this very subject – watch this space. To Dr Shibley Rahman @dr_shibley whose original thinking brightened my Saturday evening. And to David Gilbert @DavidGilbert143 who reminded me that Patient Leadership is a useful way of thinking about this. He kindly agreed to me referencing this series of articles co-written by him and Mark Doughty @markjdoughty which I would urge anyone who wants to think more deeply about this to read.
Time are indeed tough. And in tough times, it helps to know who our friends are, and whether the values they tell us they espouse are really their true values.
I send loving kindness to everyone reading this.
I took part in a Twitter chat recently on the above topic. Thanks to @AnthonyLongbone for encouraging me to join in. Below are some thoughts I shared in advance.
What does mental health mean to me?
- Mental health is the most important part of health. And it is integral to physical health. You can’t look after your body if your mind is in a poorly way.
Mental health is a continuum with optimal wellbeing at one end of the spectrum and mental illness at the other. Some people seem to be able to take good mental health for granted. For others, maintaining our mental health requires almost constant vigilance and care.
Facing up to my tendency to depression has been the most important self-help step I have taken in my life so far. I’m hopeful I won’t ever sink as low as I did in 2013. But I’m not making any assumptions. And I do not plan to judge myself negatively if I do experience another bout either.
Judging myself – or indeed others who experience mental illness – is the least helpful thing any of us can do. Who knows why I or anyone else has this tendency? What does matter is what I do from now on to help myself and allow others to help me. Which includes understanding my own triggers and warning signs.
All serious illnesses require some degree of courage, so that we can face the pain and the treatment required to help us get better. But mental illnesses can be harder to bear than physical illnesses . They mess with your head. They make you believe bad things about yourself and others. They take away your hope and they affect your judgement and even your personality. They make you isolated and afraid. Some people hear the voices of others telling them bad things. In my case, I only hear my own voice. When I am poorly, my internal voice is harsh, judgemental and cruel. It tells me I am worthless and evil. I am still learning how to notice that voice when it starts whispering to me, and how to answer it.
Since I decided to be more open about my own experiences, I have made some extraordinary friends. Our mutual support during rocky moments via social media undoubtedly saves and enhances lives. I love the equality and the loving kindness of these relationships. We all have something to bring.
It’s because of all this that I know how amazing other people who experience mental illness are. How courageous, funny, honest, thoughtful and kind – hearted. And this is how I know, beyond all reasonable doubt, that people who have had such experiences have assets that should be applauded and sought by others. Rather than deficits to be pitied or avoided.
After the chat, I felt a bit overwhelmed. The people who joined in were just amazing. Brave, honest, intelligent, thoughtful, generous and kind. I am in awe of them. They have far more of merit to say than I do.
In conclusion, what mental health means to me is being part of a group of wonderful people like the ones I was talking with tonight. They are helping me to become the best version of myself, which includes being kinder to myself. Through this, I can become kinder to others and do my tiny bit to help them too.
And I’m really grateful to be on that journey.
It was nice that 12,500 people read my two recent blogs on the mental health angle of a current The Archers storyline.
But it wasn’t all good. I am a sucker for positive reinforcement, including WordPress stats. And I doubt I will ever again get 4,500 views in a single day.
And that’s the thing about maintaining one’s mental well-being if you are one of the 1:4 people like me for whom it is sometimes a struggle. I’ve been a bit down since those two blogs. I’ve questioned whether I’ve got anything interesting left to say. And yet I know I need to write about stuff to work out what I think.
Here’s what I’m thinking about today.
Someone said to me recently, with real sincerity, that the tide is turning on the stigma of mental illness. They said they thought that the battle had been won because people like me can stand up and say that we sometimes need help from mental health services. And not be judged.
But I thought hmm.
Because it doesn’t feel that way. Not to me, nor the friends I’ve made through social media and in real life. Especially not those who haven’t been as fortunate as me and are forced to grind out an existence on state benefits juggled with occasional paid work. The positives from such work are overshadowed by arcane, dis-empowering rules of which it is almost impossible not to fall foul. Nor does it feel that way to those who live in fear of losing their homes, or who haven’t even got a place to call home. Current government policy feels deeply discriminatory and the exact opposite of therapeutic for those already experiencing the potentially crippling challenges of mental illness.
It doesn’t feel that the stigma has gone away for the people who can’t get the right mental health treatment, or even any treatment at all. As a wise person recently said, imagine telling the parents of a child with early stage cancer that they have to wait until things seriously deteriorate before they can see a specialist. And even then, the care will be rationed and probably not what is recommended. That’s the reality in many parts of the UK, for children and adults too.
I heard a senior commissioner say the other day that they would love to invest more in mental health, but the evidence just isn’t strong enough (my italics). What planet are they living on?? True, spending on mental health research is woeful. But there is nonetheless masses of really good evidence about what works. And it starts with intervening early via properly funded local services delivered by highly trained, well-supported staff.
What also doesn’t help reduce stigma is the almost constant service redesign and reconfiguration. Indeed, the billion pounds of “new” money announced by Jeremy Hunt after the Mental Health Taskforce Report was published is not, in fact, new at all. It has to be achieved through efficiency savings. I know from experience that such initiatives rarely achieve all that is promised. And they almost never take account of the collateral damage to staff well-being.
Not to mention competitive tendering, which mental health services face at disproportionately greater levels than other parts of the NHS. Plus the drip-drip reduction in mental health funding and the erosion of national data collection so that it takes the skills of investigative journalists to uncover the ongoing cuts that have been made over the past 6 years despite government rhetoric about parity of esteem for mental health.
And what adds further to the stigma is that the media rarely mention mental illness or mental health services except when something appears to have gone wrong. Where are the motivational stories like the ones about people who have “beaten” cancer? Even when no mistakes have been made, the finger of blame gets pointed. Imagine how this feels to staff who work in these services, being pilloried for doing a job that most people couldn’t begin to contemplate because they don’t have the skills, patience, courage and compassion needed to work in mental health. They should be lauded and supported, not ignored and criticised.
So no, the stigma of mental illness is not a thing of the past. It is ugly, cruel, destructive and ever-present. Like racism, sexism and homophobia, it will never truly go away. We have to be vigilant. And we have to keep working at it.
Despite the job I once did, it took me until I was 58 to get over my own self stigma and admit that I experienced clinical depression from time to time. Coming out about it was the hardest but also one of the best decisions I ever made. I take my hat off to others who have got to that point sooner than me. You are braver than anyone who hasn’t been there will ever know. Showing the world that people who experience mental illness have hopes and ideas and other wonderful human assets to share is the best way there is to make others want to join us and change the way things are.
Writing about mental health and The Archers was fun. Writing this piece was harder but far more satisfying. I will try not to care how many people read it.
Because the ones who do are the ones who matter.