Tag Archives: NHS

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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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.

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. 

There is no compassion left in the NHS. Or so reports would have us believe.

This is a cross-posting of a guest blog I did in December 2013 for the Guardian blog ‘Sifting the Evidence‘, usually written by the brilliant Suzi Gage.

Healthcare services have come under fire in 2013 for their lack of compassionate care, particularly post-mid-Staffs scandal. Mid-Staffordshire NHS Foundation Trust was found to have serious failings in provision of care which resulted in patient distress and deaths.

The QC who conducted the Francis report, the investigation into the inadequate care, identified a lack of compassion as being amongst the major causes of negligence. Since then, ‘compassionate care’ has become a new healthcare buzz-phrase, with drives to improve it in NHS trusts nationwide. Somewhat ironically, lack of compassion has also become the new stick to beat the already much-beaten NHS with.

Compassion is described in Buddhist tradition as a wish for all beings to be free of suffering and the causes of suffering. It is also defined as a capacity to meet pain with “kindness, empathy, equanimity and patience”, both in ourselves and in others.

Pain is unpleasant, frightening, sometimes even horrifying in its sadness. This is true whether it is our own or that of those around us. When we think about what compassion actually involves, being open to this pain in ourselves and in others, perhaps it becomes a little easier to see why healthcare workers might find it difficult to be compassionate at all times.

Experiencing or being around others who are experiencing physical or emotional pain can be frightening, and some jobs require this on a daily basis. Fear of being overwhelmed, or being helpless to change anything, of becoming upset and not able to recover… Fear of compassion, both towards others and towards ourselves, is one of the factors identified as getting in the way of being able to be compassionate.

Lack of time is another major impediment to compassion. An elegant experiment from 1973 observed the behaviour of 40 theology students in a situation inspired by the Good Samaritan parable. Students walking between two buildings, on their way to give a talk, encountered a shabbily dressed person slumped by the side of the road. Students in a hurry to reach their destination were more likely to pass by without stopping.

The time pressure students were under was the only factor that significantly influenced whether they stopped. Individual character traits, religious identification, and the topic of the talk they were about to give had no effect, even when the topic of the talk was the story of the Good Samaritan.

Let’s translate this to the NHS. The current, and under-reported, financial cuts , have resulted in hospitals being short-staffed and existing staff trying to do more tasks in the same amount of time. Given what we know about the effects of lack of time on compassion, can we be entirely surprised that mid-Staffs happened? This is not to excuse a gross failure of care which should not have occurred. But perhaps we can understand it, in the hope of preventing it happening again.

The Good Samaritan study has everyday implications as well. How many times have you been caught up in commuter rage when you were late for work? Or felt that you could have stopped to spend more time with someone, if only you hadn’t got quite so much that you needed to do?

The research is a warning to us all, to keep an eye on a lack of time becoming a constraint on our ability to care and connect with the people around us, whether they are a stranger in the street or a close friend.

This fits, too, with the well-described phenomenon of compassion fatigue. Particularly prevalent in workers who are exposed to high levels of emotional trauma, this type of ‘burn out’ involves caring professionals finding it hard to care as much, and therefore distancing themselves from their patients. To some extent, distance is helpful (it is hard to help someone feel less depressed if you end up empathising so much that you feel depressed yourself). But to cut off too much becomes unhelpful and can feel dehumanising, for both the patient and the healthcare worker.

Leading compassion fatigue researcher Dr Charles Figley emphasises the need to be kind to ourselves in order to be able to be kind to others. Again there are implications here for everyday life: the more we can acknowledge when we are struggling, the better we can probably deal with whatever is going on and be able to treat others better.

I asked Figley what advice he would give on maintaining compassion at this time of year. He said, “Compassion fatigue is when the price is too high for dispensing compassion. Compassion satisfaction is when the rewards for dispensing compassion assure being compassionate more. Being compassionate means considering how best to help those less fortunate and also means being kind to yourself. In the Spirit of Christmas, being compassionate involves caring for others and ourselves.”

So if fear, lack of time, and over-exposure to trauma reduce our ability for compassion, what are the factors that boost it and enable us to follow Figley’s advice? Can we learn compassion? Or is it something innate that we either have or don’t have?

Recent research by Jazaieri and colleagues suggests that compassion cultivation programmes, based on mindfulness meditation, are associated with reduced fear of compassion and a more compassionate attitude towards oneself.

This study doesn’t establish whether or not there is a noticeable effect of compassion training on compassion experienced by others. Several NHS trusts are now trialling leadership programmes which take particular notice of compassion promotion, and the outcomes of these will be interesting to see.

Whatever the results of these compassion training programmes, it has been all too easy, this year, to blame an amorphous “NHS” for failures. But what do we mean by “the NHS”? The workers? The management structures? The whole organisation? The government funding and policy direction? It feels odd to me when the government criticises “the NHS” when the NHS is a government-funded and directed body.

One of my concerns about the growing number of services and responsibilities which are being outsourced to private providers or to GPs, is that this enables the government to split off from and criticise the NHS, whilst simultaneously cutting the funding that allows the NHS to function.

The tendency in the media to blame “the NHS” is also misleading. The NHS is made up of nurses, doctors, managers, commissioners and is funded by the Government. To criticise “the NHS” often comes across as saying that all NHS workers are bad or uncaring. In fact, it might be just as valid to attribute at least some responsibility for inadequate care to a lack of funding resulting in difficult working conditions. What we saw in mid-Staffs was awful, but it was also a very human response to a chronically stressful working situation.

Compassion, both towards others and towards ourselves, has been linked to increased personal wellbeing. Maybe 2014 could usher in an attempt to take a more compassionate attitude towards the NHS. It might just end up benefiting everyone.

Coalition changes to NHS are depressing

I am feeling a sense of learned helplessness about what the coalition government are doing to the NHS.

Learned helplessness is a phenomenon associated with depression. A classic animal model of depression, learned helplessness occurs when an animal is repeatedly hurt or subjected to a nasty situation that it has no power to change. For a while it tries to change things until eventually it gives up. After this point, even when presented with opportunities to escape or change the situation, it doesn’t take them (e.g. Seligman, 1972). This has been shown in dogs subjected to shocks, in rats forced to swim (rats dislike swimming) and is thought to be seen in humans with depression too, who feel helpless to change their situations even when sometimes it might be possible to make changes.

The coalition have been buggering about with the NHS since they first got into power. Even now it feels to me, as an NHS employee, that the cuts which are being made in the NHS are talked about far more behind closed doors than they are in public media, as emphasised in a recent article in the Independent.

The danger is that I have become so weary of the relentless bad news about different governmental policies about the NHS, which seem to me to undermine the ability of the NHS to deliver what it was set out to do: free health care for all on the point of delivery, that I have started to feel that it is pointless to try to change it. In the spirit of resisting learned helplessness I am least writing some lists.

The changes that seem to me to be occurring include:

  • Cuts to how much money is available to the NHS, resulting in cuts in staff and yet no modifications in expectation of quality. This is impossible and results in dangerous situations and staff burn out
  • Increased emphasis on making the way that the NHS works more like a private business, including devising care pathways which can be clearly charged for and audited. There is absolutely nothing wrong with this in principle, but in practice more complex cases are not yet catered for in this sort of modelling. For example, in mental health services, someone with a chronic mental health problem and multiple diagnoses might need long-term service input, which won’t be accounted for by an “off-the peg” package.
  • Increased emphasis on opening up tendering opportunities for NHS and private and third sector (charity) organisations to bid for services. These services are no longer commissioned by the same primary care trusts, but by consortia which are mainly GP led. We are yet to see the impact of this, but my misgivings come mostly from tendering every few years meaning that costly tendering processes will be continually undergone, and that long-term service planning and coherence will be undermined if not impossible. In addition, GPs, whilst expert at being GPs, do not have specialist knowledge of specialist services, and will be making decisions they do not have experience of. This is more likely to result in post code lottery than any previous system.

What should they be doing instead?

  • Putting money in, instead of taking it out
  • Concentrating on supporting the positive changes in evidence based practice, for example in mental healthcare, which has been improving outcome measures and implementing initiatives like IAPT (improving access to psychological therapies)
  • Concentrating on measuring the efficiency of money put in so that results can be seen clearly.
  • Trying to make the NHS more efficient, yes, and drawing on private models to do this to some extent, e.g. trying to work out the costs of healthcare more specifically. But introducing more complex tendering processes and essentially passing the buck in terms of commissioning is not the answer. Better, surely, to try to make provision more consistent across areas or somehow tie it to local population statistics, rather than leave it entirely down to local decision making. Surely everyone no matter where they live should be able to access certain minimum standards of care.

Sadly, I think the Conservative ideology is clearly seen in the coalition policies here. Tory governments have historically prioritised commercial interests over welfare. The more they undermine the NHS the more they pave the way for an increasingly privatised model of healthcare. I wish they would be more up-front about what they were doing though, so we could at least debate the relative merits and disadvantages of the sorts of systems they have in the shadows. As it is, they are silently undermining a national service, which whilst far from perfect, is impressive in its breadth of reach and quality.