Double negatives and big girls’ blouses

Posted on September 13, 2019 by Eric Sinclair

My wife – a wise owl, who never tweets (at least in the internet sense) -remarked recently, apropos of nothing, “We wouldn’t be human if we weren’t fallible.” Despite the double negative in that statement, she had offered me a pearl of wisdom and I knew what she meant.

Earlier we had been discussing our Prime Minister’s comment across the House of Commons Chamber accusing the Leader of the Opposition of being “A big girl’s blouse”. Things being as they are, the Prime Minister who said this in early September may not be the Prime Minister by the time you read this. Come to think of it, the Leader of the Opposition may not be the same person either. At present they are

Johnson

 

 

 

 

 

and

Corbyn

 

 

 

 

 

In order to impress my wife, and offer her a pearl in return, I felt I should research the origin of the phrase “a big girl’s blouse”. I understand the phrase to be an insult directed at a man who is seen to be cowardly or weak, a man lacking in cojones. I am not sure if Mr Johnson has quite caught up with the way things are gender-wise in the 21st century, but I imagine that a number of people, male and female, found his words inappropriate, whether whispered or shouted. At least one female politician responded by telling him that if he thought women were weak, he would soon discover things to be quite different come the next election. Well, those are not quite her words, but I am sure you get the gist.

To my research: t’internet tells me the expression originated in the north of England in the 1960s and was popularized by northern-based television programmes such as the sitcom “Nearest and Dearest.” I don’t remember the programme, but Wikipedia tells me it featured Hylda Baker and Jimmy Jewel as brother and sister Nellie and Eli Pledge who inherit a pickle-bottling factory. Others will be more expert on this programme than I am. Personally, I was surprised to find that the origin of the phrase is so recent.

Dear reader, a confession. In order to produce this pearl of wisdom for her, I had to enter the words “big”, “girl” and “blouse” into my internet search engine and some of the results which appeared are wholly unsuitable as illustrations for a blog as genteel as this one. But those images were the personal sacrifice I felt I had to make in order to show my wife that I was at least able to match the pearl of wisdom she had offered me.

If you have read this far, you may wonder where all this is leading. Not much further, you will be pleased to learn. Some years ago, as head teacher of a secondary school in Orkney, I was keen to encourage our students to participate in debating. Debating sensibly (with humour allowed, of course) is a great way to learn to see things from the opposite point of view to your own, whether or not you are a young person. Our students often travelled long distances – accompanied by their long-suffering, energetic and enthusiastic teachers – in order to participate in country-wide debating competitions. They often performed well despite hours on the ferry and in the train.

Formal and informal debates are a great way for all of us to learn the art of civilised discourse. I often wonder what example our politicians in the debating chambers of London and Edinburgh are setting to our young people. Are they switching them on to what should be the stimulating world of political debate, or switching them off? Worse still, are they just encouraging the next generation of politicians and the public generally to shout angrily at one another from fixed positions? Remember Desmond Tutu’s wise words: “Don’t raise your voice, improve your argument”.

Words matter. In the wild west of the internet or in today’s toxic political arena, calling someone a “big girl’s blouse” is a fairly mild, if sexist, comment, and it’s the general angry tone of debate I’m concerned about rather than individuals’ sincerely held views. But it still matters who is making the comment, where they are making it and who is listening. Doesn’t it?

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Gardening Notes

Posted on September 1, 2019 by Eric Sinclair

1 September, and our fruit trees are doing well this year. We could never have made that statement in Orkney, where we lived for 10 years. Orkney has other compensations, however – see the header picture of this blog

Apple trees that seem to do well on Deeside in a sheltered garden – Discovery, James Grieve, Katya, which are all eaters; Howgate Wonder, which is a cooker and can just be seen at the back of this photo. We also inherited a Bramley Seedling which is intermittently good. This is the second year that our pear tree Bon Chretien has fruited well.

Like the best husbands, fruit trees, once planted, are great value and require little maintenance. Passing deer may munch the leaves, but so far they have not gone for the fruit. Provided you pick the right root stock they are relatively easy to harvest even if your balance is wobbly. In order for them to do well, you need to keep the grass away from their trunks (see above). This makes cutting the grass a bit of a pain, but that is no longer my department. It goes without saying that there is a huge difference between the flavour of fruit you’ve grown yourself and the flavour of what you can buy in the shops.

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Reflections

Posted on May 24, 2019 by Eric Sinclair

Responding to a recent survey on stroke care from the Scottish Government, I made the point that in stroke care psychological and emotional therapy should be provided where needed alongside physical therapy. In hindsight, I now feel even more strongly about this than I did during my time as a patient. I looked back at what I had written about it in my book Man, Dog, Stroke  in 2011, and I quote one of the relevant passages below. I should say that in many ways, stroke care in Scotland has moved on – though not enough. In particular, the culture around nursing care in Aberdeen is now very different from the experience I describe below. I feel I can say this with some certainty, having just stepped down after four years as a non-executive director of NHS Grampian. I am not so sure about the emotional and psychological care available to stroke patients and their carers.

Anyway, here is the relevant extract from Man, Dog, Stroke – if you would like to read more, then simply click on the link on this blog. By purchasing a copy of the book – preferably from an independent bookshop such as Deeside Books in Ballater – you will not be making me rich, as all profits from sales go to the Stroke Association in Scotland . Towards the end of the extract, I touch on the huge matter of personal identity after brain injury, If you would like to read more about that topic, I encourage you to read Lost and Found, a very accessible book by the neurologist, Jules Montague, or my ramblings in an earlier post.

 

…………………………………………………………………………………………………………………

“Akershus Hospital had been striking for its sense of calm, despite the adjacent enormous building site. Ward 11 of Aberdeen Royal Infirmary was a raucous cacophony of noise. It was Saturday evening when I was wheeled in on a trolley. Near my bed a large television set flickered garishly and trashily, the volume turned to maximum. To one side I was aware of a rank of inert elderly patients. In a room attached to the end of the ward I could hear the incessant, desperate shout of a woman calling “Nurse! Nurse! Nurse!” In another corner of the ward a gaggle of nursing staff shouted, belched, swore and gossiped at the top of their voices. They appeared to be oblivious to the noisy, desolate, hellish scene around them, seeking only to shout above it.

I wanted to run. Failing that (and obviously I did), I wanted to be back in the soothing calm of Ward S9 Akershus. Communication might sometimes have been a problem, but at least there was a general background of peace and quiet. Above all, the staff there did not shout in the presence of patients and there was no television set in the ward. During my stay in this Aberdeen ward, it seemed to me that no-one had trained the staff to look hard at how the hospital experience might appear from a patient’s point of view. A few individuals did try to make this leap of imagination and they stood out like gold nuggets in a shale pile, but on the whole, for the patient who was feeling tired and unwell (and surely that must be the majority), Ward 11 did not seem to be the place to find inner calm.

On my first full, working day in Aberdeen Royal, I was wheeled into the physiotherapy department to be assessed briefly by a harassed physiotherapist. Later in the day I was told by a young doctor that the ward I was in was really intended for ill people, and that, since I didn’t fall into that category (I assumed he was joking) as soon as a bed became available I would be moved to the Stroke Rehabilitation Unit at Woodend Hospital, a short distance away. No-one could tell me how long I would have to wait for this, but many described the Woodend Unit as a kind of stroke survivor’s heaven (“they do wonderful things there” was a typical comment), providing first class, frequent, intensive physiotherapy and general care. I assumed this would mean resuming the daily physiotherapy I had enjoyed in Norway and looked forward eagerly to the transfer there. It was now two weeks since my stroke, and I knew from the Norwegian physiotherapists that it was important to get active as soon as possible to promote recovery. I still had a vague and somewhat naïve view of what the word “rehabilitation” meant in the context of Woodend Hospital’s “Unit”. “Woodend” had a pleasantly sylvan ring to it. In my more upbeat moments, I pictured in my mind miserable paralysed patients being wheeled in there one day on a stretcher and then on another day a few weeks later striding happily and confidently out, throwing away all sticks and walking aids, having been put through an intensive programme of physical restoration all to a background of leafy calm.

I had this view partly because I still regarded the consequences of the stroke as purely physical – in my case, an arm and a leg, and to some extent a mouth, face and voice, would have to be put right with a series of tedious but necessary exercises. After all, you get ill, you go to hospital, they hurt you for your own good, you get cured, you leave, you resume your life. Isn’t that how it works?

Not with stroke.

Stroke is both instant and insidious, and every stroke is different. In simple terms, the initial “insult” – in my case a blood clot – starves part of the brain of oxygen. If the oxygen supply is not restored within a short time, the brain cells in that locality die, and so the parts of your body controlled by those cells cease to function. The body’s rather miraculous repair process gradually allows other parts of the brain to take over the functions of the dead cells (at least that’s the theory), hence recovery, which may be over days, weeks, months, years. No medical person can honestly put a time limit on how long any individual will take to recover – or indeed how fully they will recover. Awkward for the patient. Awkward for the medical staff. Awkward for the bean counters who control the system. With our money, our beans.

And there’s more.

The body is not like a computer where you can replace a faulty circuit with a new one. The body feels. The body is alive with present perceptions, past memories and future hopes. The body is human, and therefore unpredictable. So far as I could see, the medical “experts” in Aberdeen seemed to be treating my body more like a machine than a human being with a past, a present medical condition and – hopefully – a future. No one in Aberdeen spent time with me answering the huge pressing questions that constantly occupied my mind.

As I lay rotting in Ward 11, listening to the background symphony of elderly groans and farting, the harsh shouting of the nurses, and the braying of day-time television, I was gradually becoming more and more aware of the insidious effects of the stroke I’d suffered. During waking hours, I marshalled them in my mind, patrolled them in front of me one by one.

Concentration – gone. I could read words, but couldn’t concentrate long enough to read more than a couple of sentences. In any case, holding a book was difficult; holding a newspaper, impossible. Worst of all, I couldn’t concentrate on more than one thing at a time. No change there, Jo would say. But now it was serious. Friends had begun to visit me and I found that I couldn’t focus properly on what they were saying if there was another visitor talking at the next bed, or if a nurse was speaking at the other end of the ward, or if the television was switched on (it always was).

Speech – improving, but still hard work to form the words and string them together.

Emotions – in turmoil, and out of control. I could weep for Britain. Equally, if someone made a mildly funny remark, I could not contain my bursts of laughter. Surely it could only be a matter of time before I laughed at something tragic and lost a friend forever.

Exhaustion – constant and bone-sapping. The daily routine of showering and toileting supported by wheelchair and nurse left me weak and ready to sleep. I spent the whole day in bed. I slept for hours every day. I wakened every morning as if from deep unconsciousness.

Underlying all of these side-effects, a deeper nagging question – was I really the same Eric, as I had so confidently claimed to be when Jo first came to see me in Norway. I know that other stroke survivors have felt the same – are the pre-stroke person and the post-stroke person one and the same personality? How could I know for sure?

And the biggest questions of all – was life over as I’d known it up till now? Would I recover? Would I recover completely, partially or not at all? How could I help my recovery? None of the medical staff I spoke to in Ward 11 seemed willing or able to tackle these huge questions with me.

I hoped things would be better at Woodend.”

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Sūji wa dokushin ni kagiru

Posted on May 9, 2019 by Eric Sinclair

Note to Meghan and Harry –

 

“Naming that Baby after me will not change my way of life.” Archie

 

 

Meanwhile, a gold star to you if you know what the title of this post means. It may help if I tell you that it is a Japanese phrase transferred into English orthography.

Take the first two letters. Then take the seventh through to the tenth letter (still with me?) and you will realise that we are more familiar with its shortened form, sudoku.  

Anyway, back to the twenty-first century. If you do an internet search for sudoku you discover there are literally thousands of on-line opportunities to try to solve these puzzles. It is amazing to learn that there are so many different ways of rearranging those 3×3 squares of 9 individual numbers. Just writing that sentence takes me painfully back to the time many years ago when I scraped my way through Higher Maths. A few years later, the Principal of the African college where I was working corralled some of his staff into a room and asked us to declare our academic qualifications in Maths. We had just lost our sole Maths lecturer and there was no money to hire another. With quiet pride, I offered up my C pass at Higher Maths, and was promptly given part of his teaching timetable. Most of the students were content to try for a pass in the local exams, but one of them was a star of the Maths universe. My Maths teacher would have been amazed to learn that only a few years after leaving his tender care I succeeded in coaching this student through A-Level Maths by keeping ahead of him one lesson at a time. It was he who did all the hard work, but my pride was at stake and I suppose it shows that when that is the case you can manage to do almost anything – a fact well-known to stroke survivors.

Which brings me back to my relationship with sudoku. I am married to a woman who is pretty good at sudoku, and, thanks to her gentle coaching, I am a recent convert. In my pre-sudoku days, I would watch in awe, marvelling at her ability to tackle the problems offered by our daily paper. I suppose sudoku is a bit like life – there are easy problems, there are difficult ones, there are fiendish ones – and if you want a real challenge there are super fiendish ones. Johanna apparently has the ability to tackle all of these and succeed, much of the time. She is very patient and methodical in life as in sudoku, which is where we differ – significantly.

Now that I have mastered the basics, I feel I should always be able to coast through every sudoku challenge – easy or fiendish. When I succeed, I bang down my pencil with a flourish and shout “Finished!” loudly enough to make the dog jump. When I fail – which is frequently – I bang down my pencil with a flourish, vowing never to waste time on this activity any more, and shouting other words which cannot be repeated in a blog as genteel as this one.

As I said, sudoku is a bit like life, really.

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February 2019 – man removes clothing on Aboyne golf course

Posted on February 22, 2019 by Eric Sinclair

sun“It was so warm we had to take our pullovers off on the golf course.” This statement was made to me today by an Aboyne resident who had been enjoying the full benefit of a record temperature for February on Deeside.
record tempsOh, yes, Deeside is the place to be in February.

What is particularly satisfying for a Scot reading this article (from today’s Times) is the final statement:

Despite the unusually high temperatures, the southeast of England could have frost over the weekend where the skies are clear.

This is no more than people living in the southeast of England deserve. You can’t be too careful these days, so I should make clear that is intended as a wry, mildly humorous statement, not intended to offend those members of my wife’s family who live there.

You can also see from the article that temperatures last peaked at this dizzying level for February back in 1897. I thought, therefore,  it might be interesting to have a look at what else of historical interest was happening in  1897. I leave it to you to spot the similarities with the 21st century.

Here are some 1897 facts:
• Lord Salisbury is Prime Minister (of a coalition government)
• Marcel Proust meets Jean Lorrain in a pistol duel – they both miss and so the world doesn’t miss A la Recherche du Temps Perdu, a novel that many followers of this blog will have read in the original French
• Benin (Nigeria) is put to the torch by the British Army’s Benin Expedition. and the Benin Bronzes are carried back to London.
• Queen Victoria celebrates her accession to the throne with her Diamond Jubilee celebrations. Free postal delivery is granted to every household as part of the celebrations
• the Tate Gallery opens in London
• British troops are besieged by Pashtun tribesmen in Malakand, Pakistan
• the Automobile Club of Great Britain (later known as the Royal Automobile Club) is founded in London
• the first horseless, electric, taxicabs begin operating in London, swiftly followed by the first conviction for drink-driving given to London taxi driver George Smith
• physician Ronald Ross discovers malarial parasites, thus proving the mosquitoes did it
• a mill in Swansea, becomes the first building in the UK to be constructed from reinforced concrete
• the board game Ludo is patented
• Bram Stoker’s novel Dracula is published
• Anthony Eden, later Prime Minister, is born, as is the politician, Aneurin Bevan
• John Laurie, actor, famous for his role as Private Frazer in the BBC series Dad’s Army is born (“We’re doomed, ah tell ye! Doomed!”)

1897, then, an interesting year, when people in Aboyne said “Warm for February” as they chatted in the paper shop, adding “makes a change from talking about  the Queen’s Diamond Jubilee.”

2019, then, an interesting year, when people in Aboyne said “Warm for February” as they chatted in the paper shop, adding “makes a change from talking about Brexit and the Irish back stop.”

Finally adding, as they left the shop, “Do you think I’ll need my woollies on the golf course?” then, reflecting on Brexit, screaming to the world outside “We’re doomed, ah tell ye! Doomed!”

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Adolescents, adverbs and conjunctions

Posted on February 16, 2019 by Eric Sinclair

ES pictureSo, this week adolescents have featured large in our news headlines.

And please notice the “So” which is so necessary when beginning statements made by adolescents and post-adolescents and is a linguistic tic that so makes me want to scream. So, yes, adolescents. So, what have they been up to?

Well, Shamima Begum, for a start. She is a British ISIS bride who, “heavily pregnant”, wants to return to the UK, having absconded in 2015 to join the so-called caliphate in the Middle East. She wants to come back so that her child can be brought up here. One third of me says, under my breath, “Brought it on yourself, dear”; another third wonders what kind of hell it is to be heavily pregnant, aged nineteen, living in an overcrowded, stinking refugee camp – and, yes, I know she claims to have been unfazed by seeing severed heads; while the final third feels for her parents. Having spent a significant part of my career surrounded by adolescents – in loco parentis, I hasten to add – I have yet to meet a parent who does not continue to love their child regardless of the foolish things they may have done, the exasperatingly stupid scrapes they may have got themselves in to, even the criminal offences they may have committed.

I fear there are no easy or happy answers in Shamima’s case.

And then at the end of the week, there were the adolescent crowds walking out of class to scream that we need to wake up to climate change, allegedly inspired by sixteen-year old Greta Thunberg from Sweden. This is how Toby Young writes about these young people in The Spectator this week:

Greta Thunberg is everywhere, appearing at Davos, giving a TED talk, speaking at the UN Climate Conference in Katowice, and her message is always the same. Western governments are doing nothing to combat climate change.

adolescent protestersShe isn’t saying they’re not doing enough. No. She claims they’re not doing anything. ‘Everyone keeps saying that climate change is an existential threat and the most important issue of all and yet they just carry on like before,’ she says in her TED talk. ‘You would think the media and every one of our leaders would be talking about nothing else, but they never even mention it.’

Now, I admire Toby Young, who has done a great deal to challenge (constructively) the educational status quo in England. I have even publicly defended him in a letter to the Times, but on this, Toby, you need to cool, man.

Subtlety tends not to be in the nature of the adolescent. It is all or nothing. Here sixteen-year old Greta is talking – not in her native language, mind you – but talking nevertheless with passion about a matter of global significance. Yes, she may have overstated and exaggerated, but that is what sixteen-year olds do. Some of her followers in this country are equally passionate, some probably just fancied an afternoon off. How was your behaviour when you were sixteen, Toby?

Toby goes on to say that youngsters who walk out of class are causing their teachers real problems in terms of planning lessons. Even the Prime Minister has joined in on this one, claiming that “it is important to emphasise that disruption increases teachers’ workloads and wastes lesson time that teachers have carefully prepared for.”

Maybe so, but I bet that for every teacher who had to rearrange their lesson about Boyle’s Law or reschedule that stunning presentation about the past perfect tense in French reflexive verbs, there were ten who privately sighed with relief that they didn’t have that restless bunch of terminally bored, hormonal adolescents to manage during all of Friday afternoon.

And remember, those teachers and their pupils will be back in their classes in a day or two and the next day and the next day and the next day.

So, adolescents, then.

I just SO want you to lose that SO.

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Resolutions

Posted on January 23, 2019 by Eric Sinclair

Belatedly, I have begun my new year resolutions which are:

1. To keep this blog regularly updated and

2. To recover physically from the injuries inflicted during 2018 – notably the fall and broken arm last August, which put paid to driving a car and walking with Archie for a number of weeks.

By making these resolutions public, I hope to stick to them and to bore readers of this blog with regular progress reports.

Ice on Deeside is making life treacherous for some of us at the moment and I am determined not to hit the ground again this year. Exercise, therefore, must needs be taken inside. At home I have an exercise bike which proudly the displays the logo “Body Sculpture”. Well, we can all dream of that Michelangelo-type figure, which, as luck would have it, is david michelangelonot unlike my own. As the original of David is readily available on the internet, I don’t need to prove that statement by displaying my personal replica of that magnificence. Here’s what Michelangelo created, so all you need do is simply re-imagine that figure as a Scotsman with a beard.

Stroke survivors, and possibly many others, will recognise the feeling of wobbly legs and total physical exhaustion associated with exercise bikes – and that’s while getting on the bike, let alone the feeling after 5 or 10 minutes hard exercise and then getting off it again.

Having spent several sessions of simply pedalling as fast as possible, both with and without resistance, I have now embarked on the sessions that come pre-programmed into the bike. They are not arranged in level of difficulty, but come in fixed 20-minute blocks with a graph showing the imaginary hills and slopes that have to be negotiated. Program 1 looked the most appealing to me, though I have to say “appealing” is a relative term. All of them look horribly spiky and daunting, but program 1 is displayed as a round fairly even dome rising from the foothills of level 1, ascending via resistance levels 5 and 7 to the summit of killer level 9, before dipping to level 7, then ascending again to the twin peak of level 9, followed by an ever so gradual descent to level 1. No freewheeling allowed. The graph looks something like this:

20190123_150453_graph

 

 

 

 

I am assured by physiotherapists that regularly punishing myself in this way will build up strength and stamina. Because I am an optimist I choose to believe them, although after running through Program 1 for the first time, I was in no fit state to do anything other than collapse and gasp for water. After 20 minutes of seemingly endless pedalling I had negotiated the slopes and allegedly covered a distance of 6.8 kilometres. A few days in, and I have broken the 7 km barrier, and today clocked up 7.15 km. Perhaps the physios are right after all.

The trouble is, this biking on a static bike going nowhere is boring, boring, b-o-r-i-n-g. The devil on my shoulder says “Don’t bother, son.” So either I have to get music, a radio or a personal trainer to keep my interest, or I have to make public the fact that I’m doing it – hence this post.

One of the buzzwords in health care at the moment is self-management. This is the theory that people with long-term conditions, like stroke, can learn to self-manage their condition. Personally, I need that self-management to be supported self-management, because otherwise the will is lacking. In the absence of a personal trainer to provide that support, I ask you, dear reader, to provide that support by making it your resolution to follow this blog through the ups and downs of 2019 – just don’t set your resistance to level 9.

Finally, you may care to read my article about the current state of stroke care in Scotland in this week’s Scottish Review.

 

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Welcome 2019

Posted on January 1, 2019 by Eric Sinclair

A happy new year to all followers of this blog and all good wishes for 2019.

May all your troubles be small ones, and may those who care for you be generous and kind and fill your bowl with happiness. And biscuits.

Archie

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Down to earth

Posted on December 9, 2018 by Eric Sinclair

Followers of this blog may have noticed that there has been a long silence since the summer, when I wrote about the joy that is the annual stroke care audit in Scotland. Blessed relief? Serious illness? Death? Nothing so dramatic. Sometimes, your blog has to fall silent, you have to laugh, nurse your wounds and simply be grateful for your fellow man and woman.

On a pleasant day in mid-August, Johanna, Archie and I were walking through the Bell Wood near Aboyne on Deeside. Cheerful chatter and clashing opinions ricocheted snappily between Johanna and me. Archie, meanwhile, was displaying his usual mix of obstinacy, disobedience and whippety charm. Our walk was almost over when a tree root, a stone, my foot or part of the dog jumped up and caused me to fall flat on my face.

I lay floundering on the ground, unable to get up because of shooting pain in my left arm, and Johanna was unable to hoist me to my feet. After a few moments, a young woman came along, pushing her baby in a pram. She was accompanied by a little black dog. As Archie and her dog made friends and began to lick each other and me, she revealed that she also had a mobile phone, that her father was an off-duty paramedic, that he lived a short distance away and that she would give him a call. The baby grizzled slightly.

Reader, I will spare you the details, but within a few minutes the baby had cheered up and that woman’s father had me on my feet, marched out of the Bell Wood and ordered to report to Aboyne hospital forthwith. His name is Derek Grant, and Johanna and I are eternally grateful for his kindness. At the hospital, I was quickly x-rayed, strapped up by friendly staff, offered painkillers and given a video call to the emergency department in Aberdeen. The consultant there diagnosed a broken humerus, offered reassurance, practical advice and told me to be patient.

Later that day I tweeted painfully:

 

2018-10-01 (3)

 

 

Within a short time, that tweet had been re-tweeted and had acquired more than a dozen ”likes”. If that sentence means nothing to you, then you are an innocent in the world of social media – and probably the happier for it. You will have to take my word that those reactions mean people appreciated the sentiments behind what I had said.

You will notice that, in extending my gratitude, I copied in NHS Grampian and our local health and social care partnership.

For the last four years, I have been a non-executive member on the Board of NHS Grampian. It has been an interesting and challenging time, particularly as it has coincided with ambitious plans nationally to integrate health and social care. The system is not perfect – far from it. But it has been a privilege to see the commitment, energy and sheer hard work of our health and social care staff at all levels across the north-east of Scotland. It has also been fascinating to be involved in the strategic thinking that has to go on behind the scenes to make our health and social care services function at all in the cash-strapped environment in which they currently operate.

On that day in August, having just returned from a meeting about strategic plans for health care in Grampian, I was brought down to earth – literally – and experienced the system at the sharp end. I was lucky to break my arm at the very time when a paramedic’s daughter happened to be walking in the same wood; when the x-ray service in Aboyne hospital was fully manned; when a consultant was available to see me via video link from Aberdeen. A few days later an occupational therapist arrived with a shower chair and a lever to help me get out of bed in the morning. I have since received excellent physiotherapy and hydrotherapy for general strengthening. When the system works well, like this, it is great for patients. I am fully aware that it is not always so, but one constant that is always there is the willing professionalism of the people who work at the heart of it.

By comparison with many parts of the world, we are lucky to have an effective health and social care system at all. Having been silent on this blog for so long while recovering, I have had time to reflect on the four years I have spent as a very small cog in the complex machine that is the NHS in Scotland. I fear that followers of this blog may be subjected to a regurgitation of some of those thoughts in 2019 – you may care to look away now.

Season’s greetings

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Stroke Care in Scotland

Posted on July 12, 2018 by Eric Sinclair

20180712_111913_sscaApologies for the length of this post.

As I do every year, I am providing a link on this blog to the annual Scottish stroke care audit – now called the Scottish Stroke Improvement Programme or SSIP as we shall learn to call it in the densely populated world of NHS acronyms.

Those followers of this blog with long memories will quickly realise that the cover (illustrated) has changed little from last year. The same smiling therapist and the same smiling patient are there. I wonder if the patient has progressed significantly since last year; I wonder if the therapist is now a member of a fully integrated multi-disciplinary team helping to provide continued rehabilitation for stroke survivors after they have left acute care. I wonder. I wonder. At least they are both still smiling. Only the date has changed – 2017 has moved inexorably on, as it does, to 2018.

So, has the content changed? Yes, the layout has changed, once again, but maybe not the underlying message, which is – acute stroke care: probably improving slowly, though not all good, and regressing in places; stroke rehabilitation – measured patchily and wildly different across the country.

There is an introduction from the Chief Medical Officer for Scotland, Dr Catherine Calderwood, a woman for whom I have the highest regard, mainly because she has articulated elsewhere a clear vision for health care. Dr Calderwood, as you would expect, uses the word “improvement” on a significant number of occasions throughout her introductory letter, whose message is largely directed towards clinicians and other healthcare professionals.

She quotes evidenced improvements:

“…….64% patients admitted to hospital with diagnosis of stroke receiving the appropriate elements for the bundle*, a 3% increase on last year.”

The target is 80%. You decide how significant an improvement that is, bearing in mind there are real people at the sharp end of this statistic. Would such a record in terms of punctuality be acceptable on our rail network, for example?

Below is a diagrammatic representation of the “bundle”:

20180712_132449_bundleShe mentions desirable improvements relating to outcomes and quality measurements for rehabilitation with which I, along with many stroke survivors, will readily identify. Rehabilitation is a key part of the “patient journey” (horrible phrase) after leaving acute care. Most patients want to resume some sort of quality of life post-stroke, many are realistically capable of achieving this and many younger survivors desire with all their hearts to do so:

“I encourage Health Boards to provide this information for continued improvements in personalised approach to rehabilitation going forward.”

This tortured sentence is challenging to understand and includes “going forward”, that ugly 21st century phrase suggesting an optimistic but vague future towards which we are all moving and in which everything will be brighter and better. That is not quite the picture of stroke rehabilitation that the SSIP paints. More of this later.

There is an important reference in her introduction to the fact that such improvements as are described in the report are thanks to a wide range of dedicated people:

“These improvements and developments only happen because of the dedication and passion of a large number of people, from frontline staff and carers to co-ordinators and analysts, sometimes in challenging circumstances.”

Having been privileged to see some of these people at work, I’d be tempted to replace the word “sometimes” with “almost always”.

Finally, Dr Calderwood references her own impressive past papers on Realistic Medicine:

“Reducing unwarranted variation is a priority in Realistic Medicine and I encourage you to use the quality audit data and the improvement programme to seek ways to make progress towards the standards of care.”

“Progress towards the standards of care” – an acknowledgement that we are not yet reaching the standards we aspire to. This failure is much evidenced in the report. And what about “unwarranted variation” – an Orwellian understatement and the hallmark of post-acute stroke care across Scotland. In simple human terms, if you leave hospital alive after a stroke, the care you will get is a healthcare lottery depending on where you happen to live.

I have spent a lot of this post describing Dr Calderwood’s introductory letter, for which I make no apology as it sums up some key points in the audit. Her underlying message, while trying not to discourage the troops, is that things must improve. They must.

As for the details of the data, I can do no better than quote a section of the response to the audit from the Director of the Stroke Association in Scotland:

We are pleased to note the improvements outlined in the audit, but some serious challenges remain.

Most notably, we are disappointed to see a significant number of hospitals not performing well against the standard set for delivering thrombolysis**. The earlier a clot is dissolved with thrombolysis which unblocks an artery and allows blood to flow through the brain, the less disability will be experienced.

We are also extremely concerned about the delivery of thrombectomy***.

In 2017, only 13 people received thrombectomy, and currently no centre in Scotland is providing it. The Audit identifies around 600 Scots per year as potentially benefiting from this life changing treatment. A national committee has been established to plan a Scottish thrombectomy service, but the process is slow and the consequence again is that many patients have been left with worse outcomes and significant disability.

We are calling alongside Chest, Heart and Stroke Scotland for the provision of thrombectomy in Scotland to be tackled as a priority by the Scottish Government, with national funding identified by the NHS. Those eligible stroke patients in Scotland deserve the same access to this life-changing treatment as in England.

For me, this is the heart of the matter – at the strategic centre of stroke care planning in Scotland, we need ambition and vision. We seem to lack this at the moment. All the statistics we have show that, in terms of care for stroke, Scotland is falling behind many countries in the developed world, let alone our nearest neighbours in England. Page 9 of the audit is particularly blunt in this regard:

In the developed world many areas have developed Comprehensive Stroke Centres (centres that deliver all aspects of stroke care, including stroke thrombectomy). Currently there are no Comprehensive Stroke Centres in Scotland.

thrombectomyStroke is a medical emergency demanding as much urgency as, say, a heart attack. The type of stroke must be quickly ascertained and the correct subsequent procedures followed. As the report admits, hundreds of people who survive a stroke could have had a better quality of life (note the verb tense – “could have had”). In other words they could have had less disability, could have had less demands on their families, could have had less need of expensive personal care and overall could have had a better quality of life if thrombolysis targets had been met and thrombectomy had been available, for those for whom it was suitable. They are the lost opportunities – the could have hads – a silent shambling army, with damaged brains and weakened bodies, but wistful thoughts of what might have been.

Nothing worthwhile is ever achieved easily, as any stroke survivor will tell you. I may be howling at the moon, but I urge Jeane Freeman, our new Cabinet Secretary for Health, not just to make stroke care a priority, but to make Scotland a world leader in stroke care. That would be a great legacy for her, but, more importantly, it is no less than stroke survivors and their families deserve.

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* bundle – a prescribed set of procedures which must take place as soon as possible following all stroke diagnoses

** thrombolysis – an injection which must be given within four hours to dissolve a blood clot in the brain

***thrombectomy – a skilled procedure to remove a blood clot mechanically from the brain. Can hugely improve outcomes for certain patients

 

 

 

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