Why this blog has to mention The Fall

ARC West Director Professor John Macleod on the latest news from ARC West, including our Showcase, new projects and why this blog absolutely had to mention a particular Prestwich post-punk band…

Happy anniversary! It’s a year since I wrote my first pandemic blog, sitting in this chair in this room, watching the magpies build their nest in the big tree across the road. They’ve come back and I’m still here. Who knew it would last so long and how much would change? And it’s still changing. Apparently in two months it’s all going to be normal again, just in time for the solstice, which must have made the day of druids everywhere.

All change for ARC West too; we are trickling back to the office, no more than six at a time, names on Lucy’s spreadsheet. My first day back was Monday 15 March – Showcase time, the substitute for last April’s launch event cancelled by the first lockdown. As instructed by Zoe I was not wearing black, and I had brought a pot-plant. The latter was to facilitate “pimping” of my background – as Zoe described it – a peace lily draped in fairy lights and a poster about low dead space syringes – perfect. What was less perfect was my wobbly webcam and the undeniable fact that, no matter how much I adjusted the lighting, my face looked a positively Trumpian shade of orange on the Zoom test.

To provide context, I hate Monday mornings; most of the worst things that have happened to me in my long life have happened on Mondays. Lara told me she was leaving on a Monday. Her last act of sabotage was to arrange the Showcase on a Monday morning – she knew fine what she was doing though feigned innocence:

“It was the only date Louise Wood could do, it’s in her diary now”.

In her head, she’s already left, I thought.

So, my baseline Monday morning level of high distress was now further heightened by both the impending performance and my disconcerting appearance. Zoe and Lucy were in the office as well. I sought Zoe’s reassurance from a safe social distance,

“How can I stop looking orange?”

She peered at the monitor,

“It’s fine, you don’t look orange – bit red maybe, that plant’s lovely by the way!”

The Showcase was actually a great success, no thanks to me, all down to Zoe, Lucy, Liz and the team who, as usual, played a blinder. If you weren’t one of the 200 odd folk who attended you can read about it and watch the presentations, and see the feedback from the nearly 40% of attendees who provided it. Amazingly, nobody mentioned my orange face – people can be so kind.

In February, we had the NIHR response to our first ARC annual report and on 4 March our first NIHR site visit. NIHR appear to have adopted a “lull them into a false sense of security by showering them with effusive praise” strategy (softening us up for the subsequent kill). Hah! We are wise to that; we know that the next three and a half years are the real test. Up to now has in many senses been the easy bit, bask in reflected CLAHRC glory, chat about things, blame the pandemic for any problems. Conversations will continue but their place is increasingly in the past. The future is about action and, thankfully, I think we’re ready.

At the heart of our readiness is our amazing team. Mentioning individuals generally feels wrong, as it risks distracting from the fact that we are a collective, where everybody is important. So, I only mention individuals as examples of everyone’s general brilliance. Like Zoe who was recently officially acknowledged as one of the 87 most influential women in Bristol (why 87? I have absolutely no idea), or Rosie, who alongside Mike (and Andy and Jazz of course) has been the beating heart of our public involvement team for so long (long before me), who has just led co-creation of our new involvement and engagement strategy, to be enacted after she retires, her legacy. We’ll be lost without you Rosie. And Pippa, who has now officially started as our new manager – it is so good to be managed again! “Brains he might have, common sense he’s nane!” my mother always said (cheers Mum!). Though it’s Lady Bracknell’s advice I’m currently mindful of:

“To lose one manager may be regarded as misfortune, to lose two looks like carelessness.”

So, I have resolved to be more careful. In one of our early one-to-ones, I advised Pippa that should she ever be unhappy she should tell me about it, so that I can restore her happiness and thus avert her departure. I’ve been on leadership courses – rule one, don’t over-complicate things. True, Pippa did initially appear to receive this advice with as much enthusiasm as my teenage self once took similar advice from my father that I could talk to him about “any of that stuff – any time”. I thought “Dad, I would never, ever, talk to you about any of that stuff ever”. I later realised I could have talked to him about it, and maybe should have. Pippa is obviously wiser, and a little older, because at our next one to one she says,

“You know how you said to tell you if I was unhappy?” – uh, oh! heart sinks.

“Well, I’m not entirely happy I’ve completely got my head round the finances.” – phew! breathes huge sigh of relief.

Only a complete idiot would ever think they had completely got their head round the ARC finances, our financial situation is always entirely both precarious and mysterious. The factors and processes underlying it are impenetrable, mainly due to the complicated co-funding arrangements. Hilariously our partners (especially our academic partners) think we’re loaded and are always complaining we don’t give them more cash. This is just part of what Pippa has to manage, recognising the size and complexity of the challenge is the first step. Like I said last time, she’s going to be great.

You remember the “Beneficial Changes” initiative? It’s now changed its name to the ARC-AHSN Collaborative Network (wise move given the questionable assumption that all pandemic precipitated change has been universally beneficial – scrubs aside). With PenARC and our respective AHSNs we have agreed to focus on unintended consequences of alternatives to face-to-face consultation. This seems a very important question, given that in over 12 months no health worker has had a face-to-face interaction with any patient other than in full PPE. From my point of view, and I suspect that of many of our patients, this feels increasingly rubbish. I doubt if anybody who works in a call centre ever sees it as anything other than a necessity – it’s exhausting and no fun at all. Nothing like the stuff that makes interacting with patients 10 million times more ace than interacting with academic colleagues. Like the guy I was talking to about some insoluble problem who seemed increasingly distracted and disinclined to look at me rather than the window or the bookshelf, then suddenly making eye contact said,

“You know what? You’re starting to irritate me.”

I miss all that so much and I suspect not having it has a human cost, like so many of the changes of the last year. Unfortunately, quantifying this cost is likely to be tricky and it does seem a little unrealistic to think that the ARCs can give the definitive answer on the cost-benefit balance of these changes in a year, for an extra £125K per ARC, £10K of which has already been top-sliced to pay for a manager. The one ray of hope is that the manager is extremely competent, and Nicky Cullum has been put in charge – if anybody can ensure that something useful comes out of this, it’s Nicky.

Another area of impending action is around the national priorities. This is the chance for ARCs to work together “at scale”, to implement innovation and make an impact – in two years. Typically, the resource allocated to this is tiny – inevitably, it has resulted in a street fight. The good news is that ARC West have still got several projects in the ring. As well as these, Hugh McLeod has got half a health economist (always a handy thing to have) to look at value in the social care theme and Paul Moran is leading for us in NHS Check, considering the impact of the pandemic on health and care staff wellbeing, in the mental health theme.

Our front runner projects include Chris Salisbury’s extension of his 3D and ‘Year of Care’ work on personalised primary care with people experiencing complex multi-morbidity in the multimorbidity theme, and Rachel Hiller’s project on improving access to trauma-focused CBT for children in public care, in the child health and maternity theme.

I’ll declare an interest here; despite knowing that projects are like children and pieces of music and that thinking in terms of favourites is usually a mistake, I absolutely love this project. If making it happen is the only thing I achieve in the next three and a half years I’ll be happy (haha obviously I don’t mean this NIHR, Dean of Faculty of Health Sciences, bosses generally – relax, I’m just kidding). I love this project because it’s about making things better for “looked after” (a questionable adjective in itself) kids. I can’t think of another large social group in England (asylum seekers maybe?) who life has dealt a worse hand. Typically, they grow up neglected, abused and exploited – then, often after a failed attempt to get them adopted, they get put in foster care. The average length of each foster placement is around 3 months – so much for permanence. A few may end up in a longer-term placement, till they’re 18 and they’re expected to care for themselves. There are post 18 options – “staying put” where their foster carer becomes their landlord, or “shared lives” if they’ve got a recognised disability. Few care leavers avail themselves of these options. Unsurprisingly this often doesn’t go very well. Equally unsurprisingly, children in public care often experience post-traumatic stress disorder (PTSD), for which effective, NICE recommended treatments exist and are available on the NHS. But kids in care don’t get these treatments, because they don’t get diagnosed with PTSD. Instead, they typically get described as having an “insecure attachment style”, even when they present with the same symptoms as a kid not in care. Rachel and her team have shown this.

I’m not trying to over-simplify a complicated situation. Attachment, as an important issue in child development, has a sound theoretical basis and an insecure attachment style seems to increase risk of several psychological difficulties. But it’s arguably not a diagnosis and it has no readily available, effective treatment. The cause of an insecure attachment style is exposure to insensitive or inconsistent caregiving in early life – have a guess how many looked after kids were exposed to sensitive and consistent caregiving in their early years and you can start to see the problem. Describing them as having an insecure attachment style is generally just stating the obvious and runs the risk of being a therapeutic dead end, rather than a solution. It’s not about wholesale service change, it’s about changing diagnostic prejudice. Its beauty is its simplicity and it could have enormous impact – it deserves to.

To be honest I only know a tiny bit about looked after kids because 11 years ago June and I became foster carers, mainly because June was bored. Any novelty attached to moving to South West England had long worn off. The only possible advantage attached to such a move – handy for Glastonbury – turned out not to be an advantage since I wouldn’t go (I don’t do festivals, particularly one’s that look suspiciously like Disneyland for young professionals). June doesn’t give up easily. Her subsequent campaign has been conducted through the kids we’ve looked after – enticing them with the prospect of Beyonce Knowles and Ed Sheeran.

“Don’t worry” she says, “I’m buying a tent, we’ll go next Summer, Misery Guts can stay at home and write grant applications”. Their eyes light up and aren’t even dimmed by my prophecy that they’ll probably bump into their social worker. Our foster daughter who arrived 10 years ago last week and stayed, actually loves her social worker. She also makes her social worker cry. She’s always been a runner – our daughter, not the social worker – “not away, because there’s no such place” as Gil Scott Heron says on the last record he made before he died, “I would run for cover, if I knew where cover was.” Just running for the sense of freedom, the possibility of escape, the possibility of cover. Her social worker was trying to explain the hazards involved in running, the risks.

“You know out there, running, in the middle of nowhere, in the middle of the night, something really bad could happen to you!”

To which our daughter replied,

“Everything really bad has already happened to me”.

Which was when her social worker burst into tears and why we should really get our finger out and try to make things different.

Oh well, on a happier note 2020 was the year of big data and ARC West are all over it. Nish Chaturvedi’s Long Covid study, that we are a small part of, now has an acronym, CONVALESCENCE (COroNaVirus postAcute Long-term EffectS: Constructing an EvidENCE base) and has kicked off, causing my impostor syndrome to kick in big style. No worries, it’s great to be doing some science again as opposed to my idiosyncratic approximation of “leadership” (really, I am making all of this up as I go along) and I know I’m going to learn loads. Last night I listened to the latest of the BMJ’s excellent Covid “known unknowns” podcasts that was about long Covid, and was struck by the wise words of Margaret McCartney (she’s a GP in Glasgow) about the harms we risk causing by assuming we know much more than we actually do.

And the big, good news story of 2021 has been the vaccines. I love vaccines, a health technology that actually works and that within the limits of normal knowability does much more good than harm – how many of those do you know? And one of the many privileges of being a GP is that you get to play a part in this huge thing, jab people in the arm, stick the little badge on their t-shirt. The love you get is amazing (and slightly unnerving). A girl who was there with her gran spontaneously told me and my partner (we vaccinate in pairs) that she thought we were “fucking brilliant!”. She gave us both a Creme Egg, I cried in the car afterwards before eating it. I haven’t had this much fun vaccinating since Managua, July 1988. Another story for another day. And I need to namecheck Cesca, Hartcliffe’s vaccine machine, she can do north of a hundred in a shift without breaking sweat, bestriding the narrow world like a colossus. She told me the other day that she’d recently come across my blogs. This provoked the same sort of reaction as when people corner you at a public event and say, “you don’t remember me do you?” and I totally don’t. But you were very complimentary Cesca, and I said I’d make you famous.

I’ve gone on a bit – as is my habit. But I’ve forgotten the most important thing. My old mate @mendel_random doubted the authenticity of my last blog because I never mentioned the Fall once, so finally here goes.

“I sometimes think of what future historians will say of us.”

So muses Jean Baptiste Clamence to a chance acquaintance in an Amsterdam bar. He’s a middle-aged professional, driven to drink and ruin by the realisation of the hypocrisy, futility and complete absurdity of his previous ostensibly successful career. This realisation perhaps came to him when he found his name inexplicably absent on some honours list. I find him one of the most relatable characters in 20^th century fiction.

“A single sentence will suffice for modern man. He fornicated and read the papers. After that vigorous definition, the subject will be, if I may say so, exhausted.”

What would Albert Camus, author of the Fall, Nobel laureate, have made of Twitter I wonder? Probably he’d have absolutely loved it, every hour of the day, arguing about the possibility of zero Covid, @le_vrai_étranger.

Of course, @mendel_random meant the other Fall, the one named after that Fall, Prestwich’s gift to the world. I met Mark Edward Smith once, maybe twenty years ago, in a pub in Digbeth. After the gig, June, drunk as a skunk and with her mission head on, had dragged me backstage. Security didn’t even try to stop her. She plonked me in front of Mark Smith, who I recall had his left leg in a plaster cast, and told him,

“This is my husband, he’s your number one fan.”

This took me aback; Mark Smith had been known to sack band members for crimes no more heinous than ordering a salad. I wasn’t sure how he’d react to the concept of his “number one fan”, but he seemed intrigued, if not by me at least by June. Seizing her advantage, June produced a recently purchased copy of “Country on the Click” from her jacket pocket and pressed it at Smith,

“Sign this, it’s his birthday.”

My birthday is in January, this was a warm Birmingham evening in August.

But people like to accede to June’s requests, maybe sensing if they don’t they might wake up with a horse’s head in their bed. Smith took the CD and picked up a marker pen,

“So what’s yer name then?”

I was completely speechless, totally, utterly.

“Papa doc” pipes up June.

That did it for Smith, the wild man of post punk cackled, he got it. “Papa doc” was what the kids called me, in the worst possible taste, because I was their Papa, and I was a doc, not because I bore much other resemblance to a homicidal Haitian despot, albeit one who had started his career as a public health physician.

“To Papa Doc, MES” he scrawled on the CD cover. And then he talked to us for what seemed like hours but was probably minutes, about medicine and Arthur Machen and death squads and Spanakopita recipes (his wife threw that in) and stuff. June did most of the talking, as I remember. I wouldn’t say we were mates, but on one level, our minds met. He’s dead now of course. @mendel_random and I were at what would have been his last gig, but he never made it out of the hotel room. In one of those online Q&A interviews a few years back, someone asked him if he regretted never having children.

“You are all my children” he said. A beautiful answer and exactly how I feel.