Show less restraint!

Since june of last year I have been busy leading a consultation process for the DH which culminated in a guidance document being launched by Care Services Minister Norman Lamb on the 3rd of April. Its all about reducing restrictive interventions. I guess most people will think of restraint , but its more than that . it can embrace physical but also chemical processes and the most common such as environmental. That's very much about practices such as blanket security processes such as locking areas, denying access to places (kitchens etc) and just being inhibited in what you can do.
But why have these practices crept into place. Its been a 300 year old debate about the balance between freedom and autonomy and the risk to self and others when in places of care and treatment. It remains a distinctive feature of mental health services that we have the ability to compel and coerce and also have a client group that at times wishes to not only endanger others but also themselves to the point of destruction.
I have met many people in this process over the last year that are really trying to do the right thing by those they care for and yet seem frustrated by what they are required to do and also the environment of scrutiny and resources allocated for their role.
Its been a 300 year old journey, but still far from over.

Mindfulness :Week 2

So two weeks of mindfulness practice have gone by, and what a really interesting (to me) couple of weeks it has been. I am now firmly into week 3 and really enjoying it.
I think some of the major challenges have been carving out time and also reconsidering how I engage with everyday life.
It has been a challenge occasionally to undertake the meditation exercises and I have resorted to doing them on my early morning commute to London at times. But, the good news is that it can be done!
I have also reconsidered exactly what happens when I spend time just thinking. I always thought that the quiet time I enjoy in the early morning with a strong cup of Assam tea  was a moment of reflection and preparation for my day.
However, using the practice of mindfulness I can see that it was usually far from restful. It was characterised by planning, anticipating and at times ruminating over what may happen, what very probably would happen and at times what would rarely happen.Far from restful and at times quite exhausting and also pointless. So what difference can mindfulness make?
Perhaps I can give you an example of yesterdays journey to a CQC meeting in London.
My train was cancelled, then the next train was delayed.In fairness this is a rare occurrence for me but still a frustrating start and I hate being late to a meeting.
I then got onto Paddington underground station and had to wait for a Circle line train.
However, as time went on I stepped to the open sun filled end of the platform stood in the sunshine, closed my eyes and mindfully focussed on my breathing. I may have spent only a minute or two, but I felt the sun and noted the sensations coming through my feet and just stayed in the moment.
It was not only a quick destressor but a very pleasurable moment. No real requirement other than to place into practice what I have been learning.
I hope that such occurrences of using what I am learning will continue to present themselves. I wonder if you would find such means of managing everyday issues helpful to?

Reflections on the Francis Report

Firstly I am not going to rehash the content of the report which is being closely read by many more wiser than I. However, suffice to say it has provoked a great deal of comment and consternation in equal measure. I want to draw a rather strange connection (possibly) between the report and the utterances of Chris Huhne the ex cabinet minister who is currently being mauled by the media for various reasons not least being found guilty of perverting the course of justice.
The fall from grace (as its strangely known) of a public figure is always it seems enjoyed in a kind of perverse way by all of us. It's a bit like watching a train crash in very slow motion as all becomes unravelled, and the moment comes when the person involved has to make their statement, and exit in a dignified manner amongst the wreckage of their career and in this case public scrutiny of their private life.
I was most interested however, by the choice of language in his statement outside court.
He refferred to his need to accept responsibility for "something that happened ten years ago". Carefully chosen words that attempt to provide a distance and also remove a sense of ownership. Note , not something "that I did" but rather "something that happened".
Neat eh?
Almost a sort of admission but also a sense of not being personally responsible. So how does this connect to the Francis report? Well the events of the debacle that ensued in Stafford have been distilled to a pernicous and inhumane culture of an organisation that became obsessed with pursuing financial targets and in that process endangered the people it served by not providing a service that met their needs. Now many erudite verdicts are being delivered by many commentators and there are calls for resignations, and many protestations that targets should never have resulted in such a situation. Those who now provide this rational commentary are in part those who drove a culture began many years ago where the "business" of health became a reality.
So my question is really were the events of Stafford something that "happened" as if by chance or rather something "we did" by looking the other way distracted by the lure of the rewards offered and deaf to the cries of both patients and families?

The Crying Game(s)

Well its over, and we will all have our memories of what made the London Olympics memorable. For some it will be simply that they were there  either as a volunteer, a spectator or even a participant. For most of us I guess we will have consumed the Olympics by watching the television coverage.
The need for immediacy has seen athletes asked that favourite question of pundits "How do you feel" when they were barely able to speak for exhaustion, and on occasion we have seen levels of self blame and doubt that were hard to watch as they apologised to all who had supported them. The sense of failure was almost palpable.
There were of course the triumphant moments on the finishing line and the podium when the medals were awarded. which brings me to my main observation. How many times over the past two weeks have we seen the outpouring of emotion accompanied with tears? It doeesn't seem to matter what gender the athlete was; they just let the tears flow.
If the London Olympics has been a chance to bust myths such as the Tube won't run, it will rain all the time or even it will all grind to an inept halt ; then surely the one myth that has gone is that we (the British) are a repressed race of individuals who cannot show emotion. It  becomes all the more  paradoxical when you recall that just about a year ago a great deal of emotion was being expressed in parts of the capital but mainly of anger and perhaps frustration.
So are we now more comfortable with showing how we feel?
As we enter the Post-Olympic period and others will try and harness all this good feeling for various ends perhaps we can remember that summer of 2012 when Britain found it was OK to show how you feel and even share that moment with strangers.

One in four

I'm sure I have used the "one in four" statement many times. I have argued like many others before me that one in four people will have an episode of mental ill health/distress in their lifetime. The figure has been used by many to make people realise how we need to recognise and indeed de-stigmatise the number of people who need help but above all compassion for their situation.
But now we seem to have a new one in four. This new figure (actually based on a 2007 paper) argues that of those who have a mental health problem only one in four will actually be receiving treatment/help/assistance/support.So of that quarter of the population that need help only a quarter will be receiving it.
Quite an astonishing figure. Especially as the cost of this failure to treat /help is dwarfed by the savings to be accrued by returning people to a better place. As you can tell the argument is being underpinned by financial arguments (not surprising considering the London School of economics are involved) but isn't this really a moral issue?
Imagine if you will a quarter of diabetics only receiving treatment and a situation where retinopathy or gangrenous extremeties or indeed blindness were casually accepted. You can't really can you. Or even where a failure to treat for up to a year was accepted as a consequence of "how services are organised"
We do seem to be dogged by low expectations, fatalism and even a sense of nihlism when it comes to mental health.

"Homeland" and the issue of memory.

Quality drama, well thats the title afforded certain types of drama, along with the term "high production values" its meant to convey something extraordinary about what we choose to watch.
I guess the "Killing" seemd to be dominated by jumpers, "Borgen" by lamps and now the "Bridge" seems to focus on architecture and beautifully shot  enigmatic locations in Sweden  and Denmark.
But what of "Homeland" what will be your enduring memory of it? Theres no doubt it was a tense and gripping drama and not since "Twin Peaks" have I felt not only compelled to watch but also came to actually care about some of the characters. I suppose its nicely contemporary and also had that hard "real politik" with just an suggestion of dark and menacing forces (on both sides).
For me the really memorable episode was the penultimate one when Carrie became manic and distraught at the failure by others to understand and agree with her view of what was going on. I have never seen a more accurate depiction of the features of mania as she worked relentlessly to solve the problem of Abu Nasir. At the scene where her work was torn down off the wall the sound was faded and we saw her complete distress at not being believed. It seemd to me that could be the lived experience of many who we consider "unwell" or "ill". I found it sobering to see that so accurately depicted and for me will remain as an enduring memory.
Which is kind of neat as the series ended with Carrie hoping her memory would endure the ECT she was having. We wait to see if it does.

My "London face"

I was introduced to a fascinating idea the other day from a colleague who was visiting London for the day. He had at one time worked in London and then had moved to the West Country. Whilst we waited for the meeting to commence he told me that he hadn't been in London very long that day and he had found himself re-adopting his "London face". I was intrigued by this and asked what such a face looked like. He told me it was essentially a blank stare and he proceeded to demonstrate it to me.
It was as he said blank. In some ways similar to the blank expressionless stare that some people with Parkinson's disease have. Devoid of expression and at the same time a bit threatening.
We discussed what the purpose of such a stare was. He considered it was to avoid contact, in particular to avoid interactions with people who are trying to sell or beg. I was familiar with the tricky issue of eye contact on the Tube and how that took some managing on a busy trip, but this really interested me. Was it a way of keeping to oneself, or a means of keeping people away.
A look that says "don't bother me".
As I was making my way to the Tube at Oxford Circus I noticed that all three Big Issue sellers I had passed didn't offer me their magazine.
I became worried, was I wearing my very own "London face"?

NHS in shock evidence based revelation!!!

I guess like most people you have been told about the "wasteful and unproductive" NHS. Indeed the current "reforms" (like stripping out £20Billion over the next 4 years) are predicated on this kind of rhetoric. How unfortunate then that a paper profiled in todays press that has been published in that organ of leftist dissent The Lancet by Prof Nick Black  (I jest about the political leanings of that august journal) gives the lie to that assertion. In fact it produces evidence quite to the contrary. I quote from todays Guardian online.
" Black produces a slew of evidence that questions the analysis of the Office of National Statistics used to work out the productivity of the health service. The ONS looked at the return for taxpayers by comparing public expenditure with how much patients used the health service and what the outcomes were.
Black's work, the first of its kind, argues that the measures the ONS used do not reflect the substantial improvements in NHS care. It points out that between 2000 and 2009, such were the advances that a baby born in 2009 could expect to live three years longer than one born in 2000.
Black says far fewer people were dying in specialist procedures in the NHS. He notes declines occurred in adult critical care (2.4% a year), dialysis (3.3% a year), and coronary artery bypass surgery (4.9% a year).
Patients' experience of how they were treated also improved. There were annual relative increases in the proportion of patients treated within four hours in accident and emergency departments (2.5% a year) and in the numbers operated on within 28 days of their operation having been cancelled for non-clinical reasons (10.4% a year).
Such was the NHS's popularity that in the annual British Social Attitudes survey, 70% of respondents reported they were overall satisfied with the NHS. This was the highest figure ever recorded by the long-running survey – the lowest was 34% in 1997, at the end of the Conservatives' 18-year tenure in office."
An impressive record is it not? 
If all that seems a bit technical then cast your mind back to how long people waited for a hip replacement in the 80's. it seemed quite the norm then to wait 2-3 years.Now we seem content with a wait of 18 weeks.
Could this paper herald  the advent of evidence based policy? Now that would be a breakthrough!!

We've only just begun

Now I am pretty sure that was the first line of a Carpenters song in the 70's, and was probably about the commencement of a new relationship or something equally slushy (as I am sure I thought at the time). It also is true if the Guardian can be believed true of another relationship. According to an article last week by Polly Toynbee (who still gets ribbed by her call for readers to vote Lib Dem in the Election of 2010), we are also at the start of something else, another less welcome relationship. A relationship with Austerity. According to her article only 6% of actual public sector cuts planned have yet occurred. thats right readers, only 6%. Now there was no citing of sources, no references (Geneva or Harvard), so maybe she got it wrong. Say for arguments sake she's out by 300%, so  approximately 20% of projected cuts have occurred.
With a public sector payfreeze and an expensive reorganisation (marketisation) of the NHS occurring then what does this hold out for us? I wager its a bit more serious than the chatterati camping outside their Libraries in North London or indeed twice weekly bin collections.What will it actually look like? How we can envisage a rolling back of services at such a scale? How will it look in the sleepy hamlet where I live. Well mabe the libary is at risk, maybe the local schools will miss out on maintenance, day services for the vulnerable, or possibly a lessening presence  of police. Could be rubbish collection, street cleaning, or public amenities will start charging like parking at the beach . Small stuff maybe, but an eroding feeling, public morale can be vulnerable to such an approach.
To push through this we all need a belief that it can be endured, that we can tolerate the hardships (bit like winter really), and that maybe its in some way tolerable because its inevitable or even fair (just like winter).
So is this approach fair , tolerable or even something that the ordinanry citizen has caused and should pay for? If the answer is no then where will the feeling of injustice go? Here in the UK the usual pattern is to internalise distress , that could mean calls for help to  services that no longer exist. It really has only just begun.

Powerless victims?

Sometimes I catch a persons name, and especially one I haven't heard for a while and I think "I wonder what happened to them". Of course now with Google and other sourcers of information they can be tracked down if you wish. So it was with real pleasure I read an article online in Mental Health Practice by Prof Michael Traynor. It is called "Constrained by impossible ideals" and it offers (wait for it) a psycho-dynamic perspective on nursings apparent inability to resolve some of its more bedevilling contradictions. Indeed an old friends name (not Michaels...but a reference to Freud) is duly mentioned.
One of his four points to illuminate his argument he refers to is nursings apparent pleasure in "a stance of powerlessness and victimhood". This is evidenced by behaviours that are self defeatting and exhibited in that familiar process we often refer to as "wingeing".He supports this by reference to the Death Drive that Freud saw as part of his Pleasure Principle (not to be confused with the Gary Numan album of the same name), and further more this behaviour provides a degree of pleasure and relief from the conflict and tension that the role possesses.
The author really does have a valid point in his argument that nursing faces in many ways an impossible ideal, and as we know today an ideal that is the benchmark against which all nurses are judged, and publically so. Also it sems quite plausible that a powerless workforce that engages in such behaviour is of course more malleable and convenient to direct (guide, bully,influence.....take your pick)
Sigmund Freud certainly a name from the past in many ways but an interesting theoretical insight none the less
Oh just in case you think this is mere psychobabble then remember the work of Isobel Menzies in the 1960's ,quoted by many in reference to task allocation but predicated on the same underpinnings.

Collective grieving and the NHS reforms

A while ago I read an analysis of the public reaction in Greece to the austerity measures where it was argued that the nation was grieving. It wasn't an outburst of sadness or anger but a progression through the stages proposed by Kubler -Ross all those years ago. you probably remember how it goes (Denial Anger Bargainning Depression Acceptance). The commentator was asking whether the reaction of the Greek public was more than attributable to a mediterranean temprament but in fact the Anger phase of the Kubler -Ross model. Since then publication of the suicide figures for Greece would indicate that collectively they are in a state of malaise.
Could the application of that model be applied here in the UK as we face a momentous change to a nationally cherished system of health care from which we all have probably benefitted? Its hard not to see the events of the last few weeks as not a hardening of self interested stances but a real move to a phase of Anger.As any student of Kubler -Ross's model will tell you , it's not necessary to progress through the stages in a ordered sequence. So just perhaps the preceived failure of Bargainning may take us back to Anger in a way never experienced before in the history of the NHS.