It takes a community: individuals on their own can’t fix our health system

Jen Daffin reflects on the recent Bevan Commission conference, and how solving the problems faced by the NHS will take more than just trying harder.

A few weeks ago, some of us from Platfform went to the Bevan Commission conference.

We started with high hopes. A lot of the language was aligned to our work. People spoke about giving communities ownership, the need to recognise the role of inequalities, and the fact that Wales is a suitable size to be a model of change.

But like others, we were asking questions about the ‘how.’ How do we put this into practice? How do we make it a reality? I have some reflections I’d like to share on what we heard back.

Michael Marmot finished his talk with the quote “to be truly radical is to make hope possible rather than despair convincing” – (Raymond Williams, Welsh novelist & critic). We struggle with this at the best of times in mental health services, especially with the impact of austerity, COVID and the cost-of-living crisis.

We are no doubt in tough and unfair times. It has felt like that for a long time, and it feels as if they are only getting worse. We know this and we are feeling it at all levels of practice.

But what I heard proposed as solutions on the second day didn’t bring me the hope I was looking for. Many of them felt like they focused on individual blame (or “personal responsibility”) – rather than seeing the society we have built as having a huge part to play.

It can’t just be about individuals trying to be more healthy

In her remarks about addressing the NHS budget crisis, Eluned Morgan MS, the Minister for Health and Social Services, suggested we are going to have to “take more responsibility” for our health: we must “take more exercise” and “stop smoking”. These ideas are very well intentioned – but they do not address the bigger picture, and will not bring about lasting positive change. In fact, in some cases, they may make things worse.

This is because this approach is focused on putting the responsibility solely on the person: saying it’s ‘your problem’. That it is up to you to fix it – and if you can’t, that’s your fault too. You’re not trying hard enough to fix yourself.

The science doesn’t back this up. What research has found, consistently, is that these health difficulties are not individual problems of character. They are responses to toxic stress, adversity and trauma.

Research shows that health difficulties are a response to toxic stress and adversity. If you experienced these in childhood, you are four times more likely to also experience serious diseases, mental health difficulties or substance use.

If you are exposed to toxic stress in childhood (also known as adverse childhood experiences), you are four times more likely to experience heart disease, cancer, diabetes and mental health difficulties. You are also four times more likely to smoke or use substances.

If many of our health problems are the result of exposure to toxic stress, then the solutions must be organised around understanding how to prevent – and heal from – the effects of toxic stress.

Many people have tried hard to address health difficulties by themselves, and some people are successful – but many of us will struggle. And that makes people feel less valued, and more alone, hopeless and powerless; this adds to and worsens experiences of mental health problems. It also makes it harder for us to even start on the “personal responsibility” journey.

This is because, as a society, we still don’t have a good understanding the impact of trauma and what it means.

It’s about togetherness: community healing and the bigger picture

As well as our past experiences affecting our current health, research has also found that it is our current connectedness (to others, to ourselves, and to our communities) that is the best predictor of our wellbeing – not our history of adversity.

This means that we need solutions that bring people together and provide them with the relevant knowledge about toxic stress and relational health (the quality and strength of our connections to others) so they can heal, together, in their communities. This can be something as simple as singing in a choir – shown to be good for your physical and mental health. A Welsh tradition that should perhaps become a public health intervention!

When we tell stories together, in safe places, our shame dies.

This community connection is part of the work we are piloting with Save the Children in Bettws, Newport. The idea that struggling means we’re not trying hard enough adds to stigma and shame, and that shame lives within communities that feel they can’t break the cycles. It leaves generation after generation facing the same challenges.

But bringing people together helps change that: shame dies when stories are told in safe places. Alongside this, the Bettws project helps people make sense of their challenges and learn to understand toxic stress, and it supports people to feel like they can act.

The parents in these groups have done many brilliant things to help each other; far more than NHS clinicians would have been able to achieve through a smoking cessation program or a diabetes course.

Compassion inside the system: our health workers are people too

And about those NHS clinicians. I agree that the NHS needs to ensure taxpayers’ money is spent on the people in Wales, but trying to understand this solely through the lens of “trotting off to private practice and exotic countries” (another phrase from the conference) is not helpful, and misses the wider picture.

I only know two people across my time in the NHS who have left after completing their training to live abroad, but I do know many more people who left because the NHS culture was toxic – and was affecting their mental health and family life.

A recent survey of 2,100 UK employees, conducted by Visier, found that 43% of workers have left a job at some point in their career because of their manager. The poll also found that more than half (53%) of those considering leaving their jobs say that they were looking to change roles because of their manager.

We know that management-by-punishment is happening across our Health Boards – it has been well documented in the press. A 2020 NHS Wales staff survey found 16% of workers had experienced bullying, harassment or abuse by another colleague, while 10% said they had experienced the same from a manager.

Meanwhile, 14% said their health board did not take effective action if staff were bullied or harassed by other members of staff or the public. A 2021 BBC Wales news report found that there is a “culture” of bullying in the Welsh NHS which leaves people scared to raise issues.

Bullying is often a threat response to a lack of sense of safety and nervous system dysregulation or overwhelm. When we are feeling threatened, we are unable to relate to others and understand our impact. We cannot be compassionate or curious. High rates of bullying are likely a sign of the levels of toxicity and systemic trauma within our NHS services.

The solution to NHS staff burnout is not counselling on tap – and it’s not ‘resilience.’

Yes, the NHS needs reform and waste needs to be better managed – but it needs to also become a kinder, more compassionate workplace. It needs to look after the people it employs, and  that it depends on. The solution to poor workforce wellbeing is not ‘on tap’ staff CBT sessions or counselling. This only puts the problem on the person – the message becomes ‘there is something wrong with you. Why are you not more resilient? Toughen up.’

What workers want is good working conditions, fair pay and terms, enough staff and resources for their teams, and to take their breaks and finish their shifts on time. They want management and politicians to listen and to act on their concerns, and they want to be treated with dignity and respect.

Marmot laid out two things very clearly in his keynote remarks. One: that our health, including our mental health, is largely determined by our circumstances. Two: resilience is not a DIY project, but comes from having our physical, material and relational needs met. When we understand these things, we can see an obvious question: what are the circumstances making our NHS workforce sick?

Improving that sickness – both so people stay, but also so they are not working on the brink of burnout – will make for a more efficient, happier, healthier, connected NHS workforce. And, importantly, a workforce who will have the mental energy and the agency to suggest creative solutions to the many problems the NHS faces. Wisdom from within the system.

The challenges facing individuals, communities and healthcare systems are all interlinked. They are huge and complex. And although the solutions will be reached together, there is something each of us can do to bring those solutions closer. We can each try to understand what it means to be a trauma informed society – and we can apply that approach to everything that we do, and everything that we are.