NHS

#NHSChangeDay is not a distraction from #Kirkup. It is how we will fix things

This week, a number of people have been challenging those of us involved in NHS Change Day to demonstrate its value. Particularly in the light of the Kirkup report about what went wrong with maternity services at Morecambe Bay Hospitals over an extended period.

For example @GeorgeJulian wrote this interesting blog.

There are others questioning whether NHS Change Day is a cult, a cheer-leading exercise led by those with not enough to do, a distraction from the grindingly hard work of running the NHS without sufficient resources, even an opportunity for organisations to put a gloss on how tough things are for patients and staff.

I can see why they might think that. I have another take on it.

The Kirkup report was shocking, for me even more so than the Mid Staffordshire Hospitals report. It got to the heart of what can go wrong when staff go rogue and collude, when key professionals who should be working together in harmony for the benefit of patients declare war on one another, when clinicians are simply not competent to practice, and when managers, commissioners, regulators and even the ombudsman indulge in a form of magical thinking, ignoring the evidence of high rates of death and other serious incidents and accepting assurances that should never have been given. The courage of families, including the man who worked at the hospital and lost his wife and new baby, and James Titcombe and his wife whose baby son Joshua died, has been extraordinary. We owe them a debt of gratitude for never giving up and continuing to insist that the evidence must be looked at properly.

So how can NHS Change Day help? I write now as a nurse and a manager. There have been many times in my 41 years when I have been aware of something not being right. The first time I blew the whistle, I was just 18 and hadn’t even started my nurse training. You’ll have to wait for my book to read the details; suffice to say, I was ill-prepared, it didn’t go well and I was sent away with a flea in my ear. Sometimes it was me that made mistakes, sometimes it was someone else; these things can happen, and we were rightly taught always to own up if we had erred. But what about the surgeon with the shaky hands that everyone was expected to ignore, or the night sister who slept in the laundry room when she should have been supervising us? Who wants to be hated for being a sneak and reporting people who are liked, or may be experiencing personal problems?

My blood ran cold reading about those midwives at Morecambe Bay. They reminded me of maverick teams I have known. Teams who are brusque and unwelcoming however hard you try to engage them, who repel enquiries, describe managers who visit their services and ask questions as interfering, or even talk about bullying if an aspect of their working practice is questioned. And what about more senior clinicians, such as doctors, who are described by colleagues as brilliant but eccentric, and can be extremely unpleasant and difficult to deal with. The ones who write you long letters describing, with great charm, the stupidity of your ways for trying to introduce a change to improve the experience of patients. These people are the exception, but they have a massive impact. I can remember as an executive being told by a senior clinician that to expect to see the results of their clinical audit reports was tantamount to a slur on their professional standing. Eventually a brave junior member of staff blew the whistle on this person. They were dismissed for gross misconduct, upheld on appeal. But despite a ton of evidence, their regulatory body decided to allow them to continue in clinical practice.

The point I am making is that it isn’t easy to be a whistleblower, nor is it straightforward to tackle poor practice. The law is loaded on the side of employee rather than the employer, rightly so, but in healthcare this can and does affect patients.

Initiatives like NHS Change Day are the antidote. They put patients and caring, committed, non-defensive staff where they belong, in the driving seat. Leaders, including patient leaders, set the direction and tone, patients and staff come up with the ideas, and managers support them to deliver these together. Those who object to the change being proposed have the opportunity to discuss it and put the alternative case forward. Ultimately, the majority will decide. Encouraging an open, enquiring culture that is always seeking to improve practice is the best possible way for the NHS to become safer and more compassionate for patients and the vast majority of staff.

It isn’t easy always to be open to change, but we should all be learning and improving continuously.

I’m leading the Time to Change initiative for NHS Change Day. This video explains why – the key bit is from 3 mins 20 seconds. I hope it explains why I feel so strongly about change and in particular, reducing the stigma of mental illness within the NHS.

Thank you.

 

 

 

It’s #NHSChangeDay. And it’s #TimeToChange

My blog today may be the most important thing I write this year. So forgive me if I seem to be plugging it rather a lot!.

We all have mental health. And we all experience mental distress from time to time. But only some of us (1:4) get mental illness. This 3 1/2 minute video explains it well.

One of the hardest things about mental illness is the stigma associated with it. From society but also family, friends and work colleagues. But most of all from ourselves. It stops us seeking help. For example, people wait a year on average before talking to someone else about their depression. This delay causes great suffering and harm.

Time to Talk Day  took place last Thursday, part of the national Time to Change campaign. The purpose of setting aside a day every year is to open up conversations of just 5 minutes between people, and to help each other. I had some amazing conversations via Twitter and face to face with people, including at a reception for the national mental health heroes held by Nick Clegg, Deputy Prime Minister.

You may feel that politicians are jumping on the mental health bandwagon in the run-up to the General Election. But I think that’s OK. Because after the election, we can join together and hold whoever is elected very firmly to account to make sure that mental health services stop being the Cinderella of the NHS that they still are. It’s not enough for politicians to say nice things. We need carefully thought-through policies that make a positive difference, and significant investment in real terms over the life of the next parliament.

Stigma has many other negative impacts as well as on policies and funding. Time to Change have found that, while the public are gradually improving their attitudes towards people who experience mental illness, there has been no discernible improvement of attitudes within the NHS. In fact some people who use mental health services say things have got worse.

This produces all sorts of horrible results:

  • People with mental illness can be treated without the compassion and respect that are essential for effective health care
  • People with mental illness may not receive the treatment that they need in a timely manner. They may have to fight to get the right care. And they may not even receive the right treatment at all
  • The links between mental and physical illness can be forgotten or ignored, causing detriment to people with either or both. For example, people with serious mental illnesses die on average 20 years earlier than the general population, often linked to preventable diseases such as heart and/or lung diseases, some types of cancer and strokes. People are people, not single diseases
  • People with mental illness report that NHS staff can have a pessimistic outlook on their life chances, including relationships, education, employment and social contribution
  • Staff who work in mental health services can be blamed for things that are not their fault, or criticised for not providing a service when it hasn’t been commissioned or adequately funded
  • NHS staff who themselves experience mental illness often feel the need to hide it from their colleagues, and when applying for jobs. Mental illness is not seen as something to be proud of overcoming in the way that some physical diseases are portrayed

Part of our #NHSChangeDay #TimeToChange campaign asks NHS staff who have experience of mental illness to consider talking about it with their colleagues. Please be assured, we are not in any way pushing people to do this. We ask anyone who is considering doing so to think about it carefully, and look after themselves, including getting support. There are some good resources here. I know from my own experience how hard making such a disclosure can be, and how significant are the ramifications. But that takes us back to stigma. It really shouldn’t be so hard. And if we cannot be compassionate towards our colleagues who may be experiencing mental illness, how can we, and they, be expected to be compassionate with patients?

When we find ourselves troubled about something that we hold dear, it is human to want to disagree. Or run away. I felt very upset when I first heard the findings of the Time to Change research, and wanted to say no, surely it must be better than this. But then I listened again, and realised that, unless we face up to what has been uncovered about attitudes within the NHS, things will never improve.

If you have 6 minutes to spare, you can watch me talking about it here. Including the long-lasting effect that one nurse’s probably unintentional lack of compassion had on me, also a nurse.

The #NHSChangeDay #TimeToChange campaign aims to tackle this stigma within the NHS head on, with compassion, but also with wisdom and hard work. From it, we are building a programme within Time to Change that we hope will leave a very important legacy for NHS staff and patients.

Whether you are a patient or an NHS clinician, a catering assistant or a Chief Executive, please join us. Everyone can commit to one of our actions or create an action of their own. It’s NHS Change Day on 11th March 2015. And it’s Time to Change.

Thank you.

 

On Forgiveness
Drawing by Mandy Assin: Lisa as imagined after retirement

Drawing by Mandy Assin: Lisa as imagined after retirement

” In spite of everything, I still believe that people are really good at heart.” Anne Frank, written 1943, published 1947

“To forgive is not just to be altruistic, it is the best form of self interest.” Archbishop Tutu, 2010

Forgiveness is not only compassionate towards those who have done us harm. It is also good for the person doing the forgiving.  And yet, in our social media driven, accountability-obsessed world, we forget this. We seek to apportion cause, responsibility and blame within moments of the occurrence of an event that seems adverse. And then we look for retribution. Even when the case for responsibility is far from proven.

Take Dame Fiona Woolf. The initial chair of the Independent Panel into Child Sex Abuse was the eminent judge Baroness Elizabeth Butler-Sloss. She stood down because her deceased brother, Lord Havers, had been Attorney General at a point to be covered by the inquiry. Woolf, also an eminent lawyer, was hurriedly named by the Home Secretary as her replacement. It then emerged that another former member of government, Lord Brittain, might come under scrutiny during the enquiry (he since died of cancer). Woolf was open about the fact that he was a neighbour and had been to her house for dinner. A media furore ensued, and she resigned from the chair role at the end of October 2014. As her damehood was being announced in the 2015 New Year Honours List, there were calls for it to be rescinded for no reason other than that she had accepted a difficult public task.

You may not care much about Dame Fiona. She is a powerful figure. And you may not care for the honours system. But what about the nurse Jacintha Saldhana? She fell for a not-very-good hoax call to a private hospital by two Australian DJs pretending to be the Queen enquiring after the welfare of the Duchess of Cambridge during her last pregnancy. The call was played across the international media. Some people thought it hilarious, others immediately criticised inadequate security. Then it transpired that Jacintha was so ashamed, she had taken her own life. Public vitriol at once turned on the young DJs, and there could have been more tragedies.

Human beings are flawed. We all make mistakes, some of which only turn out to have been mistakes with the benefit of hindsight. When things go wrong, people need encouragement and support, so they can learn from their mistakes and improve their practice. They may need help to forgive themselves. Unless they have purposely set out to do wrong and are unrepentant, the last thing they need is public criticism. It is particularly damaging for public servants such as teachers, nurses, doctors and managers to have their motives and competency questioned by those who know little of the events in question and have never been in the position of having to do the skilled, difficult work from which the perceived error arose.

These judgemental unforgiving attitudes to mistakes cause collateral damage. The Independent Panel into Child Sex Abuse seemed unlikely ever to happen, although it is excellent news to be able to edit this post on 5th February 2015 as a third, truly independent chair has been announced. It is much needed so that the survivors can finally be heard. But sadly, since the approbation of social workers and social service departments arising from investigations into the Baby Peter case, social work practice has become measurably more conservative, with more children being taken into care, and a national social work recruitment crisis.

Judging without forgiveness makes the people doing the judging feel angry, dissatisfied and unhappy. As Archbishop Tutu showed through his remarkable leadership of the Truth and Reconciliation Commission in South Africa, and in his teachings since through the worldwide Tutu Foundation, there is no future for humans without forgiveness.

The words of Gordon Wilson, speaking on live TV just after he had held the hand of his dying daughter as they lay buried in the rubble of the Enniskillen IRA bombing were “I bear no ill will. I bear no grudge”. His calls for forgiveness and reconciliation helped lay the foundations for the eventual peace in Northern Ireland.

Throughout my career, I have tried to be honest when things haven’t gone as well as they might. I have expressed regret and apologised for failings and perceived failings, and listened and learned from people affected. This has led to improvements. But you have to keep listening.

And I have had my share of media criticism (as most chief executives do) including some unpleasant social media. This tends to be more vicious and personal when one is a woman. I began blogging and tweeting myself because I wanted to share more of who I was and what I was thinking with staff, patients and the public, and get their views directly. Although it has been difficult sometimes, I truly believe that leaders of public services do better by being open.

Some people believe that being active online makes you a target. I have thought hard about this, and I don’t accept it. It feels similar to blaming the victims of rape or other assault for putting themselves in harm’s way.

In September 2013, I announced my plans to retire from my chief executive job the following summer. I then took a big decision, to share for the first time a little of my experiences of mental illness which had occurred off and on since the age of 15. A few weeks after the second of these, I experienced a sudden onset of clinical depression, my worst ever episode. When I went back to work at the beginning of 2014, I had compassionate support. But there was also some nasty social media, just this side of legal. It continues today; it has taken a long time to learn not to look at it.

My breakdown wasn’t caused by anything anyone said about me on the internet, and I got better despite it. The causes were far more fundamental than that. It was my time to change, and I am really pleased that I did.

Because I am better now, I am able to let go of my feelings about people who say unkind and untruthful things about me. I forgive them because I imagine they must be dealing with a great deal of pain themselves. I feel lighter and better for this.

If you are online and thinking about posting a comment on someone’s appearance, motives, or actions, or even making something up about them, think about whether you would say that to their face. Not as a member of an anonymous crowd, but if you were sitting down together, as two human beings. And think about why you are reacting to them in the way you are. Jung said that we can be disturbed by those who reflect aspects of ourself we are less comfortable with; is this something you need help with yourself? I know I sometimes do.

And when someone says something unfair or cruel about you, which can happen to any of us, try very hard to see it for what it is, a remark that may say more about the other person than it does about you. By all means listen to see if you can learn from it. They may well have a point, and you can work on this. But please do not let it destroy you.

As Archbishop Tutu says, whatever mistakes any of us has made, we are all made for goodness.

POST SCRIPT, WRITTEN ON #TIMETOTALK DAY

After publishing this blog, I was pointed to a wonderful radio broadcast This American Life on cyber-harassment which is really worth a listen. A leaked internal memo shows that the CE of Twitter knows they have to do better about cyber-bullying on their platform.

And then one of the women featured in the American Life programme, Lindy West, wrote this very powerful piece about confronting someone who had said truly terrible things to her on the internet. The extraordinary results show that we must never give up on forgiveness, however hard this may be.  Even though today is #TimeToTalk day and I may sound like I’ve got my act together, forgiveness is as hard for me as it must be for any of you reading this.

UPDATE ON MY LAST POST

The trouble with listening to other people is you end up changing your mind…which is the point, I guess!

Last night I chatted briefly via Twitter with Professor Louis Appleby about the proposed “target” for suicides being zero. I got his assurances that the intention is to have shared aspiration and concerted effort towards a significant reduction rather than an aim of absolute zero. I also heard from Dr Alys Cole-King who shares his views – we have a phone call booked this afternoon to talk about how I might help with her research and how she might get involved in Time to Change.

At the Guardian debate last night, I challenged the panel to say what they were going to do personally to make sure such a policy would not have the perverse impacts feared by me and many others who, from time to time, experience suicidal thoughts.

Their answers were really thoughtful. I know some people doubt The RH Norman Lamb‘s sincerity when he says that he has been battling for mental health within the corridors of Westminster since he was appointed as Minister in 2012. But I believe him, as I do his shining conviction for much greater aspiration for people who experience mental illness, and the importance of removing silos across health and social care. I was also convinced by Professor Sir Bruce Keogh who is not afraid to speak his mind, but engages people through his emotional and intellectual intelligence, and humility. He said that the aspiration within NHS England is for real investment in mental health and to break down unhelpful barriers between mental and physical illness. He also said that Norman Lamb was on their backs about it all the time. And Julia Manning not only talked about the financial disincentives for pharmaceutical companies to invest in new treatments. She also made the audience sit forward by talking with great courage about her own experience of mental illness since the age of 22.

So where am I now? I remain unsure about an absolute zero target for suicides, because it could set people – patients and staff – and services up to fail. And I think the work of NHS Change Day and Time to Change are vital because not everyone in public services is as well-informed or humane as members of that panel. But I do now believe that a target to reduce suicides, based on the sort of thing we are doing in Brighton and Hove to become a suicide safer city, engaging the whole community, will truly change lives. Anything that gets mental illness and effective treatment and support out of the ghetto and into the mainstream must be a good thing. As Dr Mark Porter said last night, we artificially separated mental illness from physical health when we built the asylums.

Now is the time to bring it all back together, and make mental health part of health, and everyone’s business. Onwards…

 

Why I’m unsure about….

The point of a blog is to share thoughts to get others thinking. For me, the process of writing also helps me to work out what I think.

When I was chief executive of a mental health trust, I wrote a weekly blog aimed at patients, staff and anyone else who was interested. I wrote each one myself, but it was important that I sought advice from members of my team on scope and tone. I also needed to differentiate my weekly messages from things I occasionally wanted to say that were more personal, such as when I spoke about my experience of depression in October 2013.

Now I am responsible just for me, and I can say whatever I like. There isn’t much point writing a blog simply to agree with everyone else. But I am going out on a bit of a limb about the announcement on a zero suicide policy.

When I first heard about the policy, I wasn’t sure what to think. It sounded a bit like zero-tolerance, which I have issues with. So I thought I’d ask around.

I have spoken to a number of people with wise views about mental health policy. Their reactions vary. Some think that getting mental health onto the agenda is the important thing, and that this proposal has done it. Others think that this project is anti-discriminatory because it sets a clear and challenging target for commissioners and providers. Professor Louis Appleby knows a thing or two about suicide. He thinks the policy is aspirational and ambitious.

But these views are not universal.

I am grateful to Stella, who is 17 and blew me away with her thoughtful blog. She concludes that the policy may be an election ploy. And I’ve heard from a few others who fear that, without new money, it will simply be a stick to beat mental health services with. I’ve commented myself on using the NHS as a political football. Saffron Cordery also points out the need for sufficient investment.

But my main concern, developed from a few private conversations I have had with others who, like me, experience suicidal thoughts from time to time, is the impact such a policy could have on people seriously struggling with thoughts of taking their own lives, and on their families.

As I learned during the Applied Suicide Intervention Skills Training (ASIST), if you want to help someone who is contemplating suicide, you must wait for an invitation, however small or quiet, that suggests they want help. You are taught to offer support in a way that is non-judgemental and sensitive to that person’s needs and circumstances. In the 3 months since doing the course, I have used what I learned several times. We cannot allow a policy that seeks to prevent suicide to undermine the importance of such training, which is based on international best evidence. Or initiatives like Suicide Safer Cities, where communities join together to become more suicide-aware and thus safer and kinder.

The death of Robin Williams last year caused some people to examine their attitudes to suicide. The initial response to his death was shock. And then people started saying that, as well as mourning his loss, we should give thanks for his life, and applaud someone who had clearly been battling his demons for many years, and yet given so much to so many. I truly hope that this policy won’t cause people to see deaths by suicide as a failure, rather than an end to a life that was hard but extremely precious.

The loss of a loved one through suicide is extremely hard to bear. The Sick Festival in Brighton and Manchester is running concurrent sessions on this in March 2015. There is an annual service in February at St Martin-in-the-Fields for those affected by suicide. It is vital that such a policy does not undermine compassionate efforts to reduce the stigma and guilt still associated with suicide.

Perhaps I have reacted strongly because of something that happened a long time ago. In my early 20s, I took a large overdose. Luckily I was found, and taken unconscious by ambulance to A&E. As I came round, I couldn’t respond to the nurse in the rubber apron and wellingtons who was washing out my stomach because I had a thick tube down my throat and was hanging over the side of a trolley vomiting copiously into a metal bucket. If I could have spoken, I would have agreed with him when he said that I was taking him away from looking after people who were really ill, and that I was a useless, selfish, shameful waste of space. Until last year, despite deep compassion for others who feel suicidal, I believed that description about me.

Today, there are still health care professionals, and others, who think like that nurse. So if this policy, which I am sure is based on best intentions, is to have the intended impact, it must be backed up with serious investment in mental health services. Not just to bring them back to where they were before the NHS savings programme affected them more negatively than any part of the NHS, but in response to real need. And there must be a supporting education programme to make sure that NHS staff, including commissioners and clinicians across the whole NHS, view mental health on a par with and intrinsically linked to physical health. Rather than somewhere to find savings no-one will make too much fuss about, or a distraction from “real” health care.

Good mental health care does not come cheap, although in the end it saves money as well as lives. And it is about a great deal more than preventing suicide. If we can agree on that, I can support this policy. Otherwise, we may be setting services and patients up to fail.