The Tipping Point: Where next for health and care in Wales?

On 6 July my colleague Sue Newham and I attended the second day of this Bevan Commission conference at the Celtic Manor Resort in Newport. The Bevan Commission is Wales’ leading health and care think tank - aiming to “challenge, change and champion thinking and practice to ensure sustainable health and care that is fit for the future.”

Celebrating 75 years of the NHS in Wales, the conference was described as the “opportunity for an open and honest conversation about the future of our health service.” It was attended primarily by NHS and social care professionals from across Wales, and perhaps more importantly the organisers asked those attending - “What role will you play in finding ways to influence and make change?”

“We are at a tipping point. It is now time for us to face these challenges together and rebuild our health and social care systems to thrive in tomorrow’s world.” 

Bevan Commission

The day was packed with knowledgeable and inspiring speakers, presentation sessions broken up by break-out workshops where Bevan Exemplars* and others described their ground-breaking work within the NHS and social care sectors in Wales. The previous day our colleague Sharon Healey (PAVO Head of Health, Wellbeing & Partnerships) had spoken on the work of the PAVO Community Connector Service alongside Dr Carolyn Wallace (Director of the Wales School of Social Prescribing Research) in relation to social prescribing.

The key message that came out of the day for me was that the NHS can no longer continue to provide care in quite the same way as it has for the past 75 years. It’s just not sustainable. The NHS employs more people than ever before in its entire history, yet the demand for services is insatiable and cannot be met. It never will be. Because as new treatments are developed, rolled out and information about them shared, people’s expectations and demand for services increases.

The day was a bit of a roller coaster mix of highs and lows. Some of the stats around health inequalities were very concerning. But the enthusiasm for innovation, the stories I heard of good practice already happening around the UK - well, there was plenty to be excited about.

So here is a small dip into Day 2 at the conference. All of the speakers referred to challenges as well as opportunities.

"The world will not be destroyed by those who do evil, but by those 

who watch them without doing anything." 

 Albert Einstein

Frank Atherton - Chief Medical Officer for Wales

Frank spoke about some of the “wicked problems” or constraints to refreshing and carrying out the Welsh Government’s route map of A Healthier Wales - the long term plan for health and social care:

• An ageing and frail population.
• The need for the social care system to mirror the NHS.
• Vacancies in the workforce.
• Capital infrastructure is not fit for current times.

Frank also spoke about the public health agenda. In 2003 Sir Derek Wanless, a banker and health advisor, was asked to identify cost-effective approaches to improving public health, prevention and reducing health inequalities. His final report, Securing good health for the whole population, suggested that a shift in focus was needed away from just caring for the sick and into promoting good health.

Frank believes that our health is shaped by our environment. He described how all our communities are being increasingly exposed to fast food restaurants, gambling and vaping shops, for example. We need to think about how we address some of these concerns and have “deep, deep engagement with our communities.”

After highlighting some of this year’s priorities around redesigning the model Frank said that the “NHS will survive. It needs to grow, transform and develop … with public health at its absolute heart.”

Eluned Morgan - Minister for Health & Social Services

“The very fact that we have an ageing population is a sign of the success of the NHS. But we all know that the system is under strain like never before:”

More people will be living with dementia, cancer, coronary heart disease, vascular challenges, diabetes and poor mental health. And many people will be living with multiple examples of these challenges.

There is a worldwide shortage of health workers.

The vision:

• People live longer and healthier lives.
• They remain active and independent.
• They live in a whole system approach which achieves high quality care for everyone in Wales.
• Focusing not just on physical but on mental health.
• A switch to a system which anticipates health needs and prevents illness.

Eluned was clear that If we want a sustainable NHS to hand on to our children and grandchildren we need to work at managing our own health conditions, and also look at our lifestyles - around healthy diet, increased exercise, and alcohol reduction for example - to help lower the demand on the NHS. We need to listen to what matters to patients, but they also need to listen about the limitations of a sustainable NHS.

Whilst researching the conference I came across an online piece by Marion Foreman, an NHS nurse, who wrote powerfully in 2018 about an individual’s responsibility to look after their own health: Our health, our responsibility.

Prevention is key… but how to ensure that this message is heard and taken on board by the population of Wales…?

“Change will not come if we wait for some other person or some other time. 

We are the ones we’ve been waiting for. We are the change that we seek.” 

Barack Obama 

Professor Sir Michael Marmot - The Marmot Approach

Michael Marmot is Director of the (University College of London) Health Institute of Health Equity, and author of “The Health Gap: the challenge of an unequal world”.

Michael’s concern is with the social determinants of health - “the conditions in which people are born, grow, live, work and age and which can lead to health inequalities.” The 2010 Marmot Review looked at the differences in health and wellbeing between social groups and “describes how the social gradient on health inequalities is reflected in the social gradient on educational attainment, employment, income, quality of neighbourhood and so on”.

“Why treat people and send them back to the conditions that made them sick?”

People in more deprived areas used more NHS services/money than those in less deprived areas. “The UK is a very bad place to be poor.”

The framework for action created at the time of the review is known as the Marmot Principles, of which there are now 8 (the original review was revisited in 2020) - early years development (x 2), employment, living standards, communities, ill-health prevention, discrimination, and environmental sustainability. These principles have been taken on by some health boards and Gwent is the first Marmot region in Wales - Building a fairer Gwent: Why Gwent is a Marmot region.

Derek Walker - Future Generations’ Commissioner for Wales

“Acting today for a better tomorrow” - in essence sums up what the Wellbeing of Future Generations (Wales) Act 2015 is all about. “And that means in practice, for health, a long-term integrated preventative approach to our health system here in Wales.”

One of the five ways of working in the Act is prevention. Everyone agrees that prevention is key, Derek said, but not enough is happening. Derek asked “what is preventing us from putting the focus on prevention?” He pointed out that mental health issues in young people are continuing to rise, and 50% are established by as early as age 14, but there is not enough emphasis on early intervention.

Derek spoke of the 4 levels of prevention that have been developed with the Welsh Government and his predecessor Sophie Howe. Each level can reduce demand for the next. The levels start at Primary prevention - building resilience, and build up to Acute spending - which speaks for itself! “(According to Public Health Wales, mental ill health costs society in Wales £7 billion a year.”) The question now is how we spend more time at Level 1.

“We need to increase our spend on the social determinants of health faster than acute medical care spending.”

Derek noted that the Fire Service has managed to achieve massive change to bring about a 52% reduction in incidents through its investment in prevention and education. Whilst the “example doesn’t transfer automatically across to health care, it is a clear demonstration of where investment in prevention efforts can make a difference.”

A Journey to a Healthier Wales, from the Future Generations’ office, with a big emphasis on prevention and social prescribing, is well worth a read.

Professor Donna Hall - The Wigan Deal

Donna Hall, who is described as a “public service pioneer,” is the Chair of Innovative National Think Tank “Think Local”. She was awarded a CBE in 2009 for innovation in public service.

In this 2018 video she speaks to Chris Ham about what happened in Wigan, where she was Chief Executive of the council in 2011, when £160 million was taken out of their budget. They had to transform services and their relationships with the community, NHS and other providers. One of the elements of The Deal was that people took better care of their health. Amazingly The Wigan Deal improved services and resident satisfaction!

Ashley Gould - The Big Nudge

As part of this inspirational day Sue and I attended a workshop called The Big Nudge on changing people’s behaviours. It was facilitated by Ashley Gould, Programme Director of the Behavioural Science Unit at Public Health Wales. He introduced us to “Improving health and wellbeing: A guide to using behavioural science in policy and practice.”

Here in the mental health team at PAVO we’re more inclined towards the small nudge, and encouraging people to adopt positive behaviours by showing how much difference they have made to other people’s lives, specifically their mental health, be that by walking, gardening, getting active or singing, for example.

We’d like to make more of a difference, of course, and look forward to working more closely with not just the NHS but other organisations in Powys to help make the Prevention agenda key to improving people’s health and wellbeing. (We absolutely want the NHS to be around for another 75 years!) If you have any ideas about how we, and the Third Sector in Powys, could work more collaboratively to help bring prevention to the fore, then please get in touch!

You can watch videos of all the keynote speeches at this conference here.

* Through the Bevan Exemplar Programme, health and care staff across Wales are supported to develop and test their own prudent ideas to improve and transform health and care. Their projects, which are exemplars of innovation and transformation in clinical and community settings, can inform and inspire others to adopt and spread new ways of working across Wales and internationally.

World Suicide Prevention Day 2015

Today is World Suicide Prevention Day across the globe. The theme in this 13th year of the Day is “Preventing Suicide: Reaching Out and Saving Lives.”

The issue of suicide is as relevant in Powys as it is anywhere else in the world. In speaking to police officers in the local Dyfed Powys force recently I was made aware that the incidence of attempted suicide and self-harm in the county has been rising over recent months. Police officers are often the first emergency services on the scene in crisis situations, along with those from Health. Here in our team we provide an Information Service, not a Crisis Helpline such as Samaritans or C.A.L.L.Helpline, but nevertheless we are still occasionally called or met by people who are extremely distressed and tell us that they want to kill themselves.

According to the Samaritans Suicide Statistics Report 2015: Male suicides in Wales rose by 23% between 2012 and 2013, and rates are significantly higher than those in England since 2010. The BBC wrote more about these statistics here.

The question has to be asked, why are more people feeling so desperate about the quality of their lives that they consider suicide? The Samaritans Report states: 'The causes of suicide are complex, and we need to encourage people to seek help before they reach a crisis point'.

It seems appropriate then, on World Suicide Prevention Day, to flag up some of the resources and services that are available to people at risk of suicide and those close to them. First, though, a bit about the organisation which established the Day originally.

The International Association for Suicide Prevention (IASP) was founded in 1960 and is: ‘dedicated to preventing suicidal behaviour, to alleviate its effects, and to provide a forum for academicians, mental health professionals, crisis workers, volunteers and suicide survivors’.

The President of IASP, Professor Ella Arensman, introduces us to World Suicide Prevention Day with the words: “Every year over 800,000 people die by suicide (around the world)…. We now know that for many people who survive a suicide their main intent was not to die but to have a different life. This important insight should encourage all of us to become more proactive, to reach out and to support people improving their quality of life.”

Resources

Samaritans provide a helpline 24 hours a day, 365 days a year. And you can find more about the local Brecon & Radnor branch here.

C.A.L.L. Helpline offers a confidential listening and support service . Anyone concerned about their own mental health or that of a relative or friend can access the service.

NHS Choices has a very useful webpage on Offering support to someone who’s feeling suicidal. It starts off: “One of the best things you can do if you think someone may be feeling suicidal is to encourage them to talk about their feelings and to listen to what they say”.

The charity Mind has a range of information on its website relating to suicide, including sections about Suicidal feelings and Creating a support plan to use if someone is feeling suicidal.

Author Matt Haig wrote a blog post last year about the time when he nearly killed himself aged 24. It’s called REASONS TO STAY ALIVE.

Survivors of Bereavement by Suicide is a self-help organisation which exists to meet the needs and break the isolation experienced by those bereaved by suicide.

The BBC has on online guide called How do we talk about teen suicide?

Further information

In July 2015 the Welsh Government published its Suicide and Self Harm Prevention Strategy for Wales 2015-2020 - Talk to me 2. There are 6 priority actions, including:

• The development and delivery of a Wales framework for the training of professionals, individuals who frequently come in to contact with people at risk of suicide and self harm, and the general public.
• To promote staff awareness and improve staff knowledge of where to go for help and support through workplaces.

Applied Suicide Intervention Skills Training (ASIST) is run occasionally in different parts of Wales. It is a 2 day skills building workshop which prepares caregivers of all kinds to provide suicide first aid interventions. There are courses in Blaenau Gwent and Torfaen in November 2015, February, May & August 2016.

If you are urgently looking for help and advice in Powys there is a summary of the main contacts on our Powys Mental Health website.

If you have further suggestions for help and support for people feeling suicidal, then please add in the comments box below.

Finally, there is further research being carried out which aims to understand more about suicide and what can be done to prevent it. If you are interested, find out more about The Quest Study, which has been commissioned by Samaritans and undertaken by psychology researchers at Middlesex University and the University of Westminster.

Power and participation Part 1

by Jane Cooke

I have been thinking a lot about power recently. Often my trains of thought are prompted by consideration of personal power. Some people assume that they have personal power and that seems to prompt a response in others that confirms this; other people defer, give away their own power. I am not sure that this is good for anyone, but I see a lot of it. Then I wander off into thinking about structural power. Who, as a result of the position that they hold in an organisation, has the power to require or demand certain actions and responses from others?

My experiences over the years have ranged from working with groups and networks of people who use/have used mental health services to working as a counsellor for a year in a prison, to being involved in reviews of NHS mental health trusts. Throughout all of these experiences there has been a theme; that many people, no matter what their position, feel that ‘The Power’ lies elsewhere. Someone else, some other group of people or some structural body, such as a Committee somewhere has ‘power over’ services, chief executives, service users, or the ‘power to’ concede or deny, for example, a place on a joint committee or board, or to close a service or to require that changes to working practices are made, to give or withhold funding or services.

The ‘power to’ sense that individuals and groups of people can take on board themselves seems to be dimmed right now. People working in services who would like to question views and cultures in their services can feel as if they had better not stick their head above the parapet. Organisations can feel limited in their capacity to explore and support challenging ideas (and people!) if they feel that a funder ‘won’t like it’. People who might coalesce around some form of collective action, identity or pressure group can feel that such actions might jeopardise their chances of making progress in the situations where they are involved, or participate.

This feeling that some OTHER has ‘power over’ or ‘power to '(do unto us)’ both stems from and leads to fear – fear of censure, or public criticism, of withdrawal of something valued, of negative comparisons. We live in an age that generates and feeds on fear. Our many forms of communication can spread and heighten fear. Much advertising is based on promoting fear, if you don’t buy this product whether it’s insurance or some sort of ‘germ’ killer, you will be endangering yourself or those you love. Much news coverage is based on fear and a lot of political policies and promotion major on fear; capturing media interest as they do so.

But what if we moved toward a conception of ‘power with’? As far as I know these ideas of power over, power to and power with originated in the peace and non-violent direct action movements. I find them very helpful. So; power with, what would that look and feel like? I wonder if people who are involved as citizens or service users in formal situations, committees and boards, feel as if they are in a ‘power with’ situation? I’d be inclined to imagine that often they don’t. It would be really interesting to hear from those of you in such situations. Do you feel as if you are truly sharing power and if so, what leads to and supports that? In my own experience, which goes back nearly 30 years, people in these situations have been asking for parity in one form or another for at least as long as that: receiving minutes in time, important paperwork circulated in a timely manner, acceptance that agenda items can be added, access to administrative facilities as a right, recognition of the representational time-frame required if people are to be ‘representatives’, meetings at a time and place accessible to all who want to and maybe have been elected to, attend, out of pocket expenses met in cash, broadband and Information Technology (IT) costs met. I would be very interested to hear of examples where there has been ‘up-front’ thinking around these issues before people are invited to the table, before it has been brought up by those ‘reps’, or equally current examples of representatives still finding themselves in these situations.

‘Power with’ requires a shift of mind-set. Power over might appease an ego, I would venture to say that it doesn’t do much good for the soul.

Look out for Part 2 of Jane's piece on Power and participation soon. What are your thoughts? We would like to hear from you. If you have any comments or questions just add them below.

Written by Jane Cooke in her capacity as a counsellor and psychotherapist, trainer and facilitator. All views are entirely her own. Email jane.cooke@heartfeltwork.co.uk

Crisis cards or a buddy – maybe an app will do?

In North Powys members of the mental health charity Ponthafren Association can apply for a crisis card. Traditionally such a card is used to give someone chance to say how they wish to be treated in a mental health emergency when they may have difficulty in making their wishes known. The card could contain a list of useful organisations that people could contact in a crisis, and also details of someone close to the person who should be contacted to support them through the crisis.

I was interested to know if other organisations are providing cards – we are occasionally asked this question by people emailing or ringing our Information Service, and so set about researching the topic online…

What soon became clear was that most of the pages in my “crisis card” search threw up historical documents. There was much of interest to be read about the original development of the crisis card, such as the fact that: the first card to be used in this country was developed by the UK-based International Self Advocacy Alliance and jointly launched with Survivors Speak Out in 1989.

Articles going back to the nineties, when the initiative was first being developed, included detailed analysis of potential content of crisis cards. Some discussion papers seemed to imply that a paper document the size of a book rather than a simple credit style card might be required, as described in this article in The Psychiatric Bulletin in 1998.

But times have moved on… and my ongoing search then revealed that paper copies of cards are being superseded in some areas of Britain by mobile phone apps providing a similar function. In Cambridgeshire the SUN (Service User Network) has developed and promoted its own crisis card mobile phone app, which was launched with a flash mob event in Cambridge city centre in December 2013.  According to the SUN Network website: "The crisis card mobile phone app provides a one-button-press ‘call for help’, so you can reach out to your support network without having to face a phone call".

The app is free, and whilst it has been developed and designed in Cambridgeshire it is available for use by anyone in the UK.

Kate Brown, physiotherapy lead for inpatient mental health services at Cambridgeshire and Peterborough Foundation Trust, said: “The app is designed to help mental health service users in times of crisis but also as a way of monitoring their mental and physical health. We’ve demonstrated it to our ward staff and the staff have shown it to patients so they can use it after they have been discharged. It’s a new way of people getting help and it’s been welcomed by our staff and service-users.”

And mobile phone apps are not only being used to replace crisis cards but to support people experiencing mental distress in all kinds of situations. The apps are often developed by National Health Service trusts in consultation with people in contact with their services. A brief search highlighted the following readily available apps:

• My Journey – developed by Surrey and Borders Partnership NHS Trust – by staff and people using the Early Intervention in Psychosis Service.
• QDoc – developed by the Black Country Partnership NHS Trust – “to support mental health service users manage their consultations.”
• Buddy – developed by South London & Maudsley NHS Trust - clients “use text messaging to keep a daily diary of what they are doing and how they are feeling, helping to spot and reinforce positive behaviours.”

And the NHS has, on its own website, a new library page dedicated purely to mental health apps, which have “been reviewed by clinicians to ensure that they are safe and trusted.” In a digital world where it can sometimes feel that we are being bombarded by apps we can at least feel somewhat reassured that someone has checked out the app for us in advance, perhaps? (Some of the apps are free, and others have to be paid for).

What do you think about mobile phone apps aimed at supporting people in mental health crisis or emotional distress? Have you tried one? If so, have you found one you like? If you haven’t tried one, would you like to? What about the range of apps available... do they cover approaches that interest you, or are there still gaps in provision? 

Would you rather have a real life buddy, a Buddy app, or both? Let us know what you think in the comments box below.

Suicide survivors

A couple of weeks ago my sister, who manages a hall of residence at a large British university, was faced with one of the hardest times of her working life. Tragically one of the young students living at the hall appears to have taken her own life (I have to write "appears" as the inquest has yet to take place). Another member of staff and one of the student's friends found her, in her room, after she had been reported as missing all day. It is hard to imagine a more harrowing experience for that staff member and the friend. And then there is the impact upon the family, other close friends, and the wider social circle both at university and outside.

It has been described as like "a grenade going off within a family or community".

The university has arranged ongoing counselling sessions for those students closely affected which is obviously good to know. However, it got me thinking... what about other people who lose a loved one to suicide... what if there is no official support system in place... what do they do?

Well, there are a lot of resources and organisations out there which can offer support and advice.

Survivors of bereavement by suicide (SOBS) has a national helpline - 0844 561 6855, and there are local groups all across the UK. You can find out more here. The website also has links to useful books, videos, survivor testimonials, and other relevant sites.

You can link to an NHS website called Coping after a suicide.


Healthtalkonline has a section here, where you can watch interviews with suicide survivors - brothers, sisters, parents, partners and friends.

Many sites are from outside the UK, but nonetheless helpful for being so.

The Alliance of Hope for Suicide Survivors has a website page here about the common feelings which surface at a time like this. Other people's survival stories can be helpful - showing that not only is survival possible, but there is a journey beyond: "Survivors must mourn, question and rebuild their shattered lives.  For many though, there is an unexpected gift:  a bond among survivors, which pierces through the isolation and the fear."  

"RedRubySlippers" writes of her poignant journey here.

You can find many more resources online - these are just a few key links. Get in touch or leave a comment if you have some ideas that helped you.

Postscript, July 2013: The Samaritans have produced a guide called Help is at hand for family and friends bereaved through suicide and unexplained death.