Category Archives: Political

Wellbeing for all

Screen Shot 2018-06-01 at 18.28.22A new NHS framework promoting health and wellbeing in healthcare staff was launched mid-May.

The investment of time and resource to write this report is to be celebrated. The framework emphasises the importance of NHS staff wellbeing and gives some concrete ideas for improving working conditions and individual skills to cope with difficult work. These have the potential to be helpful.

However, the report ignores one of the key reasons why this document is needed in the first place: funding constraints.

The NHS is losing staff and the staff it has are under huge pressure, largely due to the mismatch between the funding available to the NHS and the funding needed. The ongoing increased need for healthcare services is well-documented although there is less coverage of how the increasing need is likely linked to the chronic and ongoing cuts to social care and early intervention healthcare.

This framework for helping staff wellbeing highlights some fantastic services where things are working well, including ones with teams dedicated to staff wellbeing and training programmes in place which try to tap into key staff values. In these services there is clear use of staff time and resource fir these purposes. This is as a result of local decisions to prioritise staff wellbeing. The framework itself lacks any ring-fenced funding attached to its suggestions so it relies on already overstretched services choosing to follow its recommendations.

When there is not enough to go around for patients, it is really hard for staff to feel comfortable with using resources for staff wellbeing, even though research has shown associations between staff engagement and better patient experience, as well as reduced staff sickness.

These links between staff and patient wellbeing are important, as are the financial savings which the framework highlights, but staff wellbeing is also important for its own sake. Working in a caring profession is hugely rewarding and also hugely challenging. Occupational risks include compassion fatigue, secondary trauma and burnout. The divide of patient and staff wellbeing is helpful for research into how staff engagement and wellbeing can affect the experience of people using services, but it risks suggesting that these are two separate groups of people who will never overlap. In reality most NHS staff are also NHS patients at some point. All people need health services sometimes, for both mental and physical health problems.

This is a human need, and thinking about how work affects us all is also a human dilemma to consider. The boundary between our professional and personal selves is not always a clear one. It moves, it changes, sometimes it feels more permeable than others. The more we can think of both patients and staff as human beings with broadly similar needs for good care, good communication and realistic expectations, the more successful I think we will be at looking after everyone. The framework is a helpful tool, but to truly champion wellbeing in healthcare services, for everyone involved, takes ring-fenced time and money to show that wellbeing for all is important.

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Cuts and knives

knife“This is a complex crime and you cannot arrest your way out of it,” said Amber Rudd this morning on Radio 4’s Today programme, as she talked about the rise in knife crime in young people in London.

I couldn’t agree more that arresting our way out of this is not the answer. But then what is? The rise of violent crime in London’s youth is complex, although sadly not surprising.

The impact of the policy of austerity on young people should not be under-estimated. Cuts to services have been brutal and chronic. Cuts to education maintenance allowance, to social service provision, to youth services such as career advice centres and voluntary sector project groups, to mentoring schemes, to child and adolescent mental health services…  the list is long. These cuts have accompanied the reductions in police numbers which are more highly reported, yet not necessarily more important.

The context that we are raising young people in is one where there are fewer and fewer resources to help them with their education, wellbeing, safety, and emotional understanding, and at the same time one where more and more is being expected of them. More frequent exams, negotiation of digital social landscapes, employment hunting in a world with fewer jobs and more expensive university fees… The environment we have created is one where there is not enough to go round, where there is huge pressure on the individual, and one in which the backdrop of “adult” discussion on the news is routinely of war and violence.

Subsequent discussion on radio 4 this morning mooted the usual suspects: the idea that we could blame knife crime on violent lyrics, or on social media. I’m surprised video games didn’t get a bit of a look in too. Of course it isn’t this simple, and of course we have more responsibility.

In the clinical settings I have worked in the violence I have witnessed has often been related to fear: a fear of being hurt, of not knowing what will happen next, of being out of control, of not knowing who to trust. Training on managing situations where someone is likely to be violent included making sure that they had a way out of the room: that they didn’t feel trapped.

What ways out are we giving young people? How are we helping them with the people and things that they are afraid of?

This problem is complex, and there is also lots more we could be doing to unpick it. The under-funding of key services mean we are raising a generation with fewer opportunities and under greater pressure. It is hard to statistically model the effects of all of the different ingredients of this cocktail, although it’s important to try, but in the absence of a clear cause of rising youth violence, I think we could be doing more to call out the common sense explanations and to do something about these. Looking at police capacity to be present is one thing, and likely important, but we can go much further than this – and look at how to increase the numbers of youth workers, youth services and youth opportunities that are available. 

Not enough mental health services to go round for young people

nspccOver 100,000 children referred to local mental health services in England have been rejected for treatment in the last two years. Figures requested from NHS Trusts by the NSPCC, released today, show that an average of 150 referrals a day are turned away from NHS children’s mental health services, despite Childline reporting record numbers of calls. From a total of 652,023 cases referred to child and adolescent mental health services (CAMHS), 109,613 children were turned away. The NSPCC has called on Government to focus on early intervention to reduce numbers who reach crisis point.

These figures are very concerning, and reflect the chronic levels of underfunding which mental health services, and in particular child and adolescent mental health services, have experienced. With ever-shrinking and unprotected budgets for child and adolescent mental health and social care, services are sometimes pushed to raise the threshold for access higher in order to prioritise high-risk and crisis cases. It is mad that a system there to help young people should have to wait until they are in crisis before it can.

Not every assessment should necessarily result in access to a service – some referrals aren’t appropriate and some young people could be better helped in other ways, but these sky-high numbers suggest that the need for mental health services for young people is much greater than the provision. In addition the care received in different geographical areas of England differs, so waiting lists and access to services depends on where you live. This data is only for England but we know other areas of the UK and Ireland are also affected by stretched services, with Wales in particular suffering from having very little access to evidence-based talking therapies for children and adults.

It’s important these figures don’t become yet another stick to bash the NHS with.The data shows a greater need than there is capacity for, which is different from showing that the services themselves aren’t good. There is simply not enough service to go round, which is not OK.

What might help? Several things:

  • Ring-fence current funding and increase it. There has been a huge amount of rhetoric about parity of esteem between mental health and physical health problems, but until there is parity of funding it is hard to believe this. Child and adolescent mental health funding in particular has had such a chronic lack of under-funding for so long that it needs even more growth in funding to be able to provide the care that young people want and that professionals want to be able to give.
  • Getting in there early. Providing good services early on before mental health problems become severe and enduring is crucial. This doesn’t mean cutting back on specialist services – we still need them – but it does mean also making sure there is enough funding for early intervention to try to nip problems in the bud and also enough funding for the education and social care supports that need to go alongside.
  • As well as early intervention we can think about prevention: putting more effort in even earlier, perhaps in school settings, to help young people understand and negotiate powerful emotions and have the emotional literacy they need to talk about their feelings, might help head off some of these problems before they begin.
  • Thinking about why these young people are so distressed. The rise in numbers of reported mental health problems in children may be partly to do with increased knowledge of mental health issues and increased ability to speak up, but it’s also likely to have much to do with the huge pressures young people are under. There are more exams than ever before, there are new social media pressures to encounter, it’s really hard to be a young person in our society today and we should be addressing that.

50% of adult mental health problems are already present at the age 14. If we could help young people avoid this we might set them off on a different trajectory for their adult lives.

#notfunny

g2

I had a good laugh at the Guardian G2 headline the other day suggesting that the patriarchy might be dead. The cover had a load of pictures of the hashtag #metoo.

It’s really important that more people are speaking up about experiences of sexual abuse or harrassment, talking about the extent of the problem and trying to call it out for what it is – totally unacceptable. But I think difficulties we face around sex and gender, as a society, run too deep for a hashtag to overturn them.

This cover came in the wake of all the Weinstein revelations and then Gove’s crass joke on Radio 4 comparing an interview with John Humphries to sexual assault, a joke which all the men in the interview laughed along with. I’ve heard several men (and some women) since complain that it wasn’t worth pulling Gove up on this, or that it’s not possible to make a joke anymore.

Jokes about taboo subjects happen all the time, and black humour is part of human coping, but that doesn’t mean it’s not better to call it out when lots of older white men are laughing about a rape joke. I haven’t called out every person who has tsk-ed about the Gove comment – probably (and not commendably) partly because I thought they’d think I was a nag, and partly because I just felt tired at having to explain this stuff. This post is me saying how I see it.

Rape doesn’t just happen to girls and women, but it does happen much more to girls and women. Girls and women are encouraged from childhood by our society to be well behaved and compliant in nature, to dress attractively, and girls are routinely praised for prettiness over skills or accomplishments in a way that boys are not. Women are objectified and sexualised from so young that they take it for granted that part of their self-esteem is dependent on how their looks are perceived by others. Boys and young men are also socialised to see women and girls as sexual objects, and the wide availability of porn coupled with sparse sex education and very little opportunity to talk about issues of emotional relationships and active consent, mean both young men and young women are often left woefully alone with knowing how to negotiate sexual and romantic relationships.

A context which tolerates jokes about rape is a context which minimises sexual assault. When we then tsk at women who complain about this, and ignore the presence of the power imbalances which are often part of harassment situations, we create a culture where the boundaries between compliments and harassment get blurry, where power dynamics are unacknowledged, and where it is often too difficult to say #metoo. It’s all part of the same picture.

The psychological consequences of rape and sexual assault are insidious and far reaching. Rape is one of the worst things that can happen to someone. The effects on sense of identity, self-esteem and peace of mind can be so deeply devastating that they are sometimes simply unbearable. Post-traumatic stress disorder, depression, anxiety, not to mention shame, self-blame, self-harm, sometimes suicide, these are possible consequences of rape and sexual assault. Working as a clinical psychologist, I have been in the privileged position of having conversations with many young people who have experienced sexual trauma, most (although not all of them) girls and women. The experiences these young people have withstood are awful. These experiences have not happened in a bubble. The culture that these girls and women have grown up in, that we have all grown up in, has at best enabled and at worst encouraged the treatment they have experienced.

We are so far from the end of the patriarchy that that G2 cover made me laugh. But not because the situation we are in is remotely funny.

King’s Fund summary calls for focus on better value, not cost reduction

Productivity in the NHSA clear summary from the King’s Fund published this month outlines the findings from their “Better value in the NHS” full report. Responding to the recent call for £22 billion efficiency savings, it highlights the key point that: “focusing on the monetary value of the challenge risks missing the real essence of the task… which is about getting better value from the NHS budget.”

Thinking about how to provide best possible care in the most efficient way is less of a turn-off than the usual narrative of NHS budget constraints. Most healthcare professionals are sick as a parrot of news about cuts and deficits, but The King’s Fund describe three areas where the NHS has already been successful in promoting efficiency: generic prescribing, length of hospital stay and day-case surgery.

The King’s Fund have rightly noticed that framing the challenge in terms of improving value rather than reducing costs is much more likely to engage clinicians in thinking about how to do this, which ultimately is probably the only way that meaningful and beneficial change will happen.

The coalition’s NHS: what do the stats say?

Screen Shot 2015-05-05 at 19.09.46With the UK election nearly upon us I was curious to see some of the stats in this King’s Fund report on the NHS under the coalition government.

The main figures I was interested in backed up my personal experience of working in the NHS since I began in 2005: namely that there has been much less funding available in the last five years than in the five years before. Whilst on the ground this is seen in job cuts, salary freezes and service pressures, the report breaks down the actual funding, employment stats, and patient and staff experiences.

Some of the key points:

  • NHS funding has increased in real terms over the term of parliament, but by a very small amount: between 0.6 and 0.9 per cent.
  • To see just how small this is, we can compare it to the growth between 1996/7 and 2009/10, which was 5.6 per cent, or to the average annual growth since 1950, which has been 4%.
  • The funding has been much less than the estimated 3 to 4 per cent real growth that we needed to cope with the costs of increased health care demand and new technologies.
  • Numbers of bank and agency nursing staff have dramatically increased recently. Between 2012 and 2015, total numbers of hours requested by acute trusts for agency and bank staff more than doubled. Why? From 2009 to 2013 there was a dip in nurses employed, followed by a recent upturn (post 2013, and after several major inquiries into quality of care in the NHS). The recent increase in nursing demand has been difficult to recruit to, and has largely had to be filled by bank and agency staff. This means more chance of being cared for by a nurse who does not usually work in the ward where you are being treated.
  • The number of NHS staff reporting that they feel unwell due to work-related stress has increased from 9 per cent to 38 per cent between 2010 and 2014.

The report ends “…even in the toughest of times financially there are always choices that can be made. Now, as the economy recovers, if the NHS is to play its part in ensuring that each health care pound is used as effectively as possible… there needs to be a matching commitment on the part of the public and future governments… in ensuring that the right level of funding is made available.”

Worth bearing in mind on Thursday as we make our choice.

This blog is my personal opinion, not that of any of the organisations I work for. 

UK Government’s Child Mental Health Taskforce Publishes Report

Screen Shot 2015-03-22 at 14.57.06Last week the UK Government’s Child Mental Health Taskforce published a report: Future In Mind – Promoting, protecting and improving our children and young people’s mental health and wellbeing.

As a clinician working for part of my week in an NHS acute psychiatric ward for 12-18 year olds, I welcome this focus on children and young people’s mental health, but I can’t help but feel a sense of unease about some of the recommendations.

The key themes the report outlines are:

  1. Promoting resilience, prevention and early intervention
  2. Improving access to effective support – a system without tiers
  3. Care for the most vulnerable
  4. Accountability and transparency
  5. Developing the workforce

Nothing to argue with there – some might say, but reading the report I had three main worries:

1. The vagueness, in parts (not all) of the report, in specifying how these goals are going to be achieved when designing services which need to be clear in their purpose and coherent in the way they fit with other services. There are some helpful ideas e.g. suggestions for commissioner training, and building on existing good practice in terms of coordinating young people’s care. There are also areas where there is a lack of attempt to crystallise ideas into more practical suggestions for coherent service structure, with nebulous “transformation plans” and other jargon referred to.

2. The lack of consideration of why a ‘tiered’ system exists – namely that different young people present to services with different severity of problems, and need different environments and treatment to manage this care. We need to respond differently to different levels of clinical risk and a tiered system allows us to do this more effectively and more safely.

3. The total lack of acknowledgement of cuts to outpatient child and adolescent mental health services (CAMHS), and to social care services responsible for children and young people’s well-being. These funding restrictions have contributed to the difficulties which the remaining CAMHS and social care teams face in meeting targets relating to waiting times. The report refers to government money spent on inpatient beds, Children and Young People’s Improving Access to Psychological Therapies programmes (CYP-IAPT), and MindEd resources. It is great that these are receiving funding, but simultaneous devastating staff cuts in other CAMHS services are also happening. The language around this report talks about CAMHS needing a “culture shift” and an “overhaul”, but to remove funding and then criticise CAMHS for not meeting targets or not embodying patient-centred care as much as it should feels nonsensical.

I’ll be watching developments with interest, and hoping that my concerns prove unwarranted.