Othello in the rain

I went to the final night of Othello in the annual outdoor production at Stafford Castle.

It was set in 1950s, in Venice and in Cyprus.

It is probably 40 years since I last read Othello, so the play felt for me quite new. I knew the tragic conclusion but I had forgotten the tangled story that leads to it.

I came to the play after a hard day’s work, but it held my attention completely, right up to the end, in the pouring rain, just before midnight. One reason for this was the way in which it was prompting me to think about troubling issues in  our world now.

Coming so shortly after the EU referendum it was an uncomfortable reminder that the racism that fuelled Brexit has deep roots. The language Shakespeare uses to explore this is very direct, I doubt that anyone could or would say such things now, but the Brexit vote gives us a window into some dark places, the things people do not say.  Shakespeare's words challenge us.

I had gone to the play with a question, “what exactly is Iago’s problem?” I am not sure that I have a clear answer, (I am told his motivation is strongly disputed by academics).

What this production showed us was an Iago who was a disappointed man. Often patronised, often overlooked. possibly sexually conflicted. He is just a trusted aide, not expected to be the main player, but his controlled and controlling presence dominates the stage. He talks directly to the audience, selecting individuals, with a word or a look, making all of us complicit.

He has scores to settle, and he uses his undoubted powers of persuasion, his understanding of human weakness, to control all of the players in his play. He takes pleasure in all of this. We watch with horrified fascination.

I thought about the persuaders in our time now, politicians, press barons, commentators, and the way in which they use words to sow the ideas that will take root in people’s hearts and grow there, out of sight; Poisoning people from within.

The play gives us a troubling insight into attitudes to women, and to domestic violence, all of which has a particular resonance today for people like myself who follow the archers. Iago, like today's villain Rob Titchener needs to control and weaves an ever more complex web that will finally trap him too.

The powerful physical presence of the actor playing Othello  (Oliver Wilson) is a shocking reminder of the menace of a strong man in the grip of  ill-conceived jealousy.

Like most of Shakespeare’s tragedies it ends in blood, with the killings directly or indirectly driven by Iago.

I did not fully grasp from the production that Desdemona was a mere child of 14 marrying a career soldier and diplomat some 20 years her senior. That too is obviously a pretty difficult matter, given one of the other preoccupations of today’s world.

I could not say it was an enjoyable evening, but I am glad that I went, and I am glad that somehow, against the odds the Gatehouse Theatre manages to keep on giving us a Shakespeare play. Here is hoping for many more.

There is probably a catch.

Many years ago I used to work in Oxgangs in Edinburgh. This is at the centre of the current scandal of faulty school buildings built under a PFI contract within the last 10 years.  The current popular narrative is that the PFI (public Finance initiative) contract is in some way the cause of the faulty construction.

It is a narrative that suits people on both sides of our political system. The Left despise PFI because they see it as a infection from the Right.  The Right use PFI as a whipping boy because it was widely used under New Labour.

The history of PFI is of course that it was designed and began to be used under John Major, probably as a response to the fact that many public sector buildings were in a state of disrepair after years of underfinancing, and that it was embraced by New Labour, in a major rebuilding spree to renew services.

The current narrative is that PFI is the problem. I cannot help thinking that this is simplistic. To me PFI looks more like a symptom.

The voting public want good services.  They do not want to pay more tax. Taxing intentions are a prominent part of any election campaign. The political parties are united in allowing the voting public to believe  that they can have the services they want without the pain of having to pay for them.

This fundamental dishonesty means that the government of the day – of whichever complexion, has to resort to magical thinking and magical accountancy. PFI is part of that.

Another interesting question raised by the current scandal in Edinburgh is “did faulty construction begin with PFI?” I think the answer to this is definitively “No!”

I spent some years working in another part of Edinburgh in the 70s and 80s.  As a welfare services officer in the housing department in Wester Hailes I was frequently called out after fires in the stairways of the densely packed modern flats of this estate.  These fires it was ultimately discovered were caused because the construction firm that built the flats had substituted a lower grade of plastic for the flame resistant grade specified by the architects. Kids who enjoyed a good fire discovered that the plastic to the drying greens could easily be ignited by a cigarette lighter. The fires were a major contributory factor to a modern estate quickly becoming an area where no one would choose to live.  The desire to light fires is probably down to cramming thousands of flats into an area where 100s would be a better fit.  We wanted a cheap solution, and that is what we got.  The fires are apparently still an issue today.

Down the road in Hailesland there used to be a group of multi storey flats, built in the 60s. These are no more, The problem was that the heavy concrete cladding that formed the exterior skin of the building started to fall off.  On investigation it was found that the steel clips which should connect the panels to the building structure did not always fit.  The builders improvised. The panels eventually fell off and all the residents had to be moved out and the flats were knocked down.

I happen to know about these events in Edinburgh, but I would be astonished if similar things have not been happening for a very long time in many parts of the country.

It is right to feel concern about the quality of buildings built with public money, but let us be realistic. If we want services that work well, and help people live good productive lives then it is necessary to pay for them. If we see options that promise to give us the services on the cheap then we should probably make the effort to read the small print. There is probably a catch.

So what is Rob’s problem?

 

Reflections on the Rob and Helen storyline from the Archers.

Perhaps a daily soap opera is the only way to tell the Rob Titchenor story. It is hard to know what is more interesting, listening to the story itself, or watching the growing group of people who are actively sharing the listening experience and working through their powerful responses to it on #thearchers.

We don’t know what the story writer has in mind, or just how dangerous this clearly damaged man will become, or how and when the tower of lies will come crashing down.

We worry about the impact of his behaviour on all those around him, the wife just beginning to fight back, the child living in the shadow of it all, and the unborn baby.

For many of the listeners the priority is that this character (who we constantly have to remind ourselves is just fictional), should be found out, stopped, shamed and punished.

Because this is a soap opera it has to have a daily cliff hanger, and maybe at times this risks tipping Rob into being a pantomime villain, a monster that we can hiss at and hate.  For me the worry is that if you strip away the demands of the drama we may not be looking at a unique monster at all.

The story coming to us now is perhaps in the tradition of public service broadcasting, It is telling us about a change in legislation. It is aimed at changing behaviour.  Rob is of course an extreme figure, but many of the elements of “coercive control” may be far more common than we could like to think.

I wonder about the circumstances that created Rob, and about the right way of dealing with men who may tend to behave in these ways that we have now legislated against.

We are getting clues about the back story of what made Rob Rob. There was trouble, as yet unspecified in childhood, He was bundled off to prep school far too young. He learning how to act tough, learning how to bully in the process, and  he found a way to shine through competitive sport.

We guess at the level of expectation which fed into his notions of what a man should be. We guess at his employment history , leaving one job after another in difficult circumstances, a trail of failures, and maybe also of criminal behaviour waiting to find him out. We see a confused, inadequate man acting tough.

We know that this is someone to whom deceit comes quite naturally. Whenever there is an error, or a flash of temper, there comes the automatic cover up, so rapid he may not even know he is doing it,  adding to the tower of lies that looks ever more precarious.

He must be desperate to keep control, and the anxiety makes him more prone to mistakes, which means more cover ups, more vulnerability.

We live in a culture that puts a premium on being tough, manly, in control, being a winner. There is no shortage of people who will play act this part, to do this they must first deceive themselves. Building a narrative of the person they choose to be. 

There are moments when the clash between this self-image and the reality can become intolerable.  When Rob hits Helen he cries. He knows this is not the way it is meant to be. Men should not hit their pregnant wives,  but within seconds he has persuaded himself that it is not his fault, he is the victim of the impossible situation created by her supposed illness.

Having shared in the collective experience of seeing Rob, I find myself seeing flashes of Rob in people around us. There are the manipulative charmers, the over-persuasive salesmen, the CEOs, trying to hold together shaky organisations, the managers who blagged their way into jobs they are not up to, the politicians who have to persuade both themselves and us that they have it all under control, the aggressive interviewers or presenters trying to frame arguments.

We glimpse also the homophobia, and the distrust of women and the discomfort at the growing presence of women in positions of power. We sense their fear that these women, given half a chance can prevent a man from being a “real man”.

Someone like Rob does not come out of nowhere; they are part of the fabric of our world.

For Rob, the chances are that this will all end pretty badly, but should we be satisfied with that? Men will only end up in prison for domestic abuse if their behaviour becomes pretty extreme, and they will then probably only be locked away for a short time. They will emerge still young, still able to do it all over again, and probably more damaged and dangerous than when they went in.

So my questions are “What is Rob’s problem?” and “What is the way to prevent people becoming like Rob, or helping them to escape from the dangerous and destructive behaviour?”

Rob’s problem may be that his idea of being a real man might have seemed “almost normal” in past times, but is now a very bad fit with our idea of what a man should be.

Rob is not without courage or skill. His qualities or recklessness and aggression would have been valued at a time when our ancestors needed to band together for the task of hunting and killing a wild boar. He would have had the esteem that clearly matters to him freely given, but now we do not have a use for him, and that is a problem.

Here we are looking at an expensively educated young man, who is not able to find a way, and is stumbling from job to job, becoming a dependant parasite, but there are so many other young men, so much less equipped to look after themselves or families in the way that they think they should.  The frustration this brings is corrosive. This can be a tragedy for them, and dangerous for those around them.  Many of the people who will be caught up in coercive control cases will not have had the supposed advantages of the fictional Rob.

I do not know where the Archers story will take us, I hope we will find out how Helen can gradually heal from the damage done to her, but I also hope that we will understand more of what created this character, and how men like Rob can be helped to find a positive role for themselves in our challenging and changing world.

 

Upsetting.

It made me sad to listen to the interview with Lord Laming on BBC radio 4 Today 23/06/15

http://www.bbc.co.uk/programmes/p02vd99n

He was being asked about the number of young people in the care system who end up in the justice system. He clearly has a kind and wise understanding of the needs of vulnerable children.

He was being asked how do you make Social work a profession people want to do when the stakes are so high, and there is so much blame, and how can you give continuity of care to young people if social workers are dropping out of the profession.

He was asked if he thought that the changes that had come into effect as a result of his recommendations on the Victoria Climbie case  http://www.publications.parliament.uk/pa/cm200405/cmselect/cmeduski/40/40.pdf or the Baby P case http://dera.ioe.ac.uk/8646/1/12_03_09_children.pdf  had contributed to an oppressive target driven culture, and the morale problems within social work

His heartfelt response was “I would find it very upsetting that anything that I had said would lead to a bureaucratic response. to all this”.

It made me think about how we as a country deal with scandals.

The pattern seems to be this:

·         Something happens that grabs the attention of the media, and it dominates the news agenda. Government immediately goes into “something must be done” mode.

·         There is no simple answer so they select a respected person to review and make recommendations.

·         This eminent person makes a sincere attempt to understand the complexity and produces a considered report which has to include recommendations.

·         The recommendations will normally imply the need for greater spending.

·         The government has to be seen to respond positively to the recommendations, It will tend to select those recommendations that do not require extra spending.

·         The government will need to prove that the recommendations are being followed, so it will bring in some kind of system for measuring the actions or outcomes.

·         Boards all over the country will incorporate these measurement systems into their governance systems, and the figures will become a focus for future anxiety.

·         The media may fail to understand the complex picture that the detailed reports have given us, but will focus on the “failings” made visible by the governance systems.

In almost all cases what these reports, brought together by sincere people who have thought deeply about the issues , will recommend that there needs to be joined up thinking, connecting the work of different organisations with the focus on the individual.

In almost all cases these deep recommendations will remain untouched, because no one knows how to make different organisations, each struggling with budgets that will not cover the costs, begin to work together effectively.

Is there an alternative to "clipping" care visits?

BBC radio 4 Today’s programme for 13/05/2015 http://www.bbc.co.uk/programmes/b05tllvh picked up on two of the big themes that will be central to concerns in Health and Care for the foreseeable future.

The first is a cry for help from care staff working for a private sector care company. Staff have drawn attention to the fact that they are being expected to “clip” the times on Home visits, to make it possible for them to travel to their next appointment, and have on occasions been told to leave a patient who has fallen, where they are, on the floor, with the door open for the emergency services to come in. I suspect that we will see much more of the same. The interview then went on to talk with Andrea Sutcliffe from the CQC.  John Humphrys from BBC Today characteristically went down the path of blaming the individual care providers and demanding that they should be penalised. I think he is missing the point.  

The second is that the Academy of medical royal colleges is asking GPs and the public to avoid asking for unnecessary interventions. The £22bn cost savings that the NHS has agreed to make, in order to get the £8bn injection of cash from the government (from a source that is not yet specified) will mean that the health service has to stop doing things. The interview with Dame Sue Bailey of Aomrc  shows that Aomrc advocates working closely with patients to help them understand when interventions may be of limited value.

http://www.bbc.co.uk/news/health-32703632

 http://www.bmj.com/content/350/bmj.h2308

 

Both of these items show the financial pressures on our health and care systems are huge, and show that meeting the growing needs of the next few decades is going to be pretty challenging.

From the view point of Stafford it is clear that the problems in our acute NHS, both at the time of the exhaustively documented local problems in 2006/7 and now, is that there are many people within the hospital system who would be better off being  “somewhere else” if the “somewhere else” exists.

Successive governments (and perhaps also voters) for the last two decades or more have dodged the questions of where should frail elderly be cared for, by whom, and how should we pay for it.  

There is broad acceptance that the only way the NHS can be made to cope is by much closer integration with the social care services. The details of what that should look like are in many cases still to be worked out.

So far it seems that the only people who have fully grasped the implications of the fact that to cope acute hospitals must discourage unnecessary admissions, and must discharge patients more quickly, are the entrepreneurs offering private sector care schemes.  The result of that is that we are seeing the growth of a whole range of social care providers, with care staff, often on minimum wages, being forced to travel some distance between one “customer” and the next. Even if these schemes sincerely wish to provide excellent services, the cards are stacked against them.

We need to understand what integration really means, and we need to think carefully about realistic ways of delivering an integrated service.

Private sector care providers have a simple objective. They need to get into homes for the time specified by the person paying for the care, and deliver the specified service. What an integrated service needs is for the care providers to be a key part of the whole business of monitoring the health of the individual, calling in additional help when required and doing what is necessary to help prevent the individual from having to go into acute care. An integrated service also requires that if an individual is discharged from hospital they can receive the additional help they will need during a period of rehabilitation.

Do the private sector companies that exist now have the necessary skills and motivation to play this role?

To me this seems to be a key moment. The Health service is changing and the care service must change too. Do we know what we want to see? How can it be made to work for both the individual “customers- patients” (I don’t even know what words we should be using) and for the individual carers providing these services.

As care shifts from hospitals into people’s homes, there will be a constant stream of stories about people left after a fall, without food, without company, without access to WCs. We know this will happen. What are our views on this? Is there a better alternative?  

It is a depressing picture, but we have to find our way through this.  For me there are at least some  pioneering projects pointing us in better directions.  I would strongly advise that people should read Atul Gawande Being Mortal  http://atulgawande.com/book/being-mortal/  This matters because it looks at the distressing effects of unnecessary treatments, and looks at different ways of providing the essential social care that we must provide.

I would also advise looking at the Buurtzorg model http://www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdf This very local approach is where I would wish to start in the process of building integrated care that works.

7 Day working for NHS. So how would that work?

We are into the period when the political parties try to bring out their eye catching policy initiatives.

David Cameron has said that if in government they will bring about 7 day working for the NHS.  http://www.bbc.co.uk/news/32094681

 

This is of course a discussion that has been going on for at least the last 5 years. It is clearly desirable for patients that there should be access to services 7 days a week, but there are also reasons why so far the move towards this is patchy.

The responses to the proposals so far seem to be on the lines:

• ·         It won’t happen.

• ·         There is no money to pay for it.

• ·         Where are you going to get the staff?

Personally I think that it would happen – but at a cost.

It is clear that there is no additional money on the table so how could 7 day working be made to happen?

If we were in a position where hospitals worked in co-operation with each other, one could imagine the creation of networked provision so that there is cover for a range of different conditions provided in different centres during weekends. This would make good use of existing facilities.

But we are in a position where hospitals compete with each other, and there is insufficient funding, especially for acute & emergency services, and there is a finite pool of staff in many areas.  All of this means that only a limited number of hospitals will in the end be able to provide 7 day a week services.

Ability to provide seven day consultant services will in these conditions become a proxy for a hospital’s ability to survive in a situation where there is competition for scarce resources, and media focus on hospitals "failing" to provide a seven day service will drive patient choice.

The reason why I think that this policy will seem attractive to some is because it will drive the centralisation of services. The provision of 7 day services will happen in the big centralised hospitals, and the smaller DGHs will see another step in the downgrading of what they can offer to their communities.

There is also of course the potential for private enterprise to set up or run acute centres to provide the weekend cover.

So yes – expect 7 day consultant services to become a reality, just don’t expect it to be in a hospital near to where you live.

 

What does the future hold for our hospital?

Tomorrow night the Borough Councillors in Stafford will be asked to support a motion for a referendum on the hospital.  I have no way of knowing how that will go.

I have talked to thousands of people over the last few years the frustration and anger at the loss of services has been very apparent. Maybe a referendum will give people a way of expressing this feeling. It might also leave people free to use their election vote to choose the party that they see as offering the right option for them and for Stafford on the many different pressing issues that face us all.

In the years since the Stafford crisis broke there have been many changes in the health service, not least in the way in which hospitals are supported if they hit a tricky patch.  I think that everyone in the Department of Health recognised the harm that was done to Stafford by the years of reports, reviews, inquiries, and the administration process.  Now when it is recognised that hospitals are in trouble, both in financial terms, and in terms of attracting and retaining staff they get placed into “special measures” with the clear intention of turning them around.

In Stafford the reverse of this happened. The Investigation of 2008 isolated the hospital. The turnaround that was attempted in 2009 did not work – in part because of the strongly orchestrated demands for a Public Inquiry.

The first Inquiry gave patients and families a chance to have their voice heard. This was valuable and has certainly had a big effect on thinking within the NHS as a whole. It did also strongly make the point that there are genuine difficulties in managing the care of frail elderly people in our hospitals.

The second Inquiry always seemed to me to be about Andrew Lansley’s desire to demonstrate the structural flaws within the NHS, and to justify his reforms. These reforms were imposed and are now generally accepted to have been a very costly and distracting mistake.

The Inquiries and all that followed  have month by month eroded any possibility for our hospital to recover in its original form.

So if the motion tonight is passed – and if the referendum takes place and is overwhelmingly passed  what then?

Personally I believe it is naïve to think that we can return to the way things were.  Staff and teams  are scattered, the hospital and the whole health economy of this part of the country remains in serious financial trouble.  

The health service is changing. Most of us accept that there are some services which are best performed in large hospitals with specialist equipment and consultants on hand 24/7.

Improvements in surgery and other treatments mean that care which in the past may have needed a hospital stay can be done as day case treatment, much of which can and should be done as locally as possible.

The development of monitoring systems means that patients can play a major part in controlling their own conditions and staying well.

It is also recognised that acute hospitals are not the right environment to support and rehabilitate very frail elderly people.  The aspiration is to provide much more care for people in their own homes, to prevent unnecessary admissions, and to help them recover with their families around them.  That raises very serious questions about the availability and cost of social care and community nursing.

When the dust from the Election, and the referendum if it happens, has settled then I believe that there is an important role for all of us in mapping out the right future for our hospital and the wider health services in our area. It is unlikely to be the same as it was – but by working together perhaps we can make it better able to cope with the massive challenges that lie ahead.