It may be that in writing this blog I am cursing myself; I have fingers, toes and legs crossed and am holding on to a piece of good solid wood, all for luck and against sod’s law.  I hope nothing happens to derail me because I wrote this down!

I have spoken at events recently about ‘resilience’ and I have been pondering what it means.  If resilience is important for people with long term conditions to have full lives, where they bounce back from inevitable setbacks, how can we help people to build resilience? or do some people just have it and others not?

One of the meanings of resilience is the ability of something to spring back into its original shape, an elasticity that helps things to retain their form. But I think this is unhelpful when thinking about health or indeed most aspects of life; life events, no matter how positive or negative they are, shape us as people and for many of us leave indelible marks. I think the definition that includes the word ‘adjustment’ is more helpful; after things happen to us, it is our ability to adjust and move on that makes us resilient.

Remember Weebles?  Wobbling but not falling down? See also this brilliant blog from @betabetic about Resilience, Weebles and personal stones.

So, am I a resilient character? I think so. Having reflected, I think it is a learnt behaviour. I was a child of a broken home, although I still had a very happy childhood. The broken home part led to me taking up responsibilities probably beyond what you would expect of a 15 year old; I effectively ran the home and ended up moving out into rented accommodation at 17. I didn’t go on to do further study at 16, leaving school to earn money so I could completely support myself. My reflection is that my learnt behaviour, to be independent and self-sufficient, is an attitude that has continued into by Diabetes life. I have had a few curved balls thrown at me and I doubt that I have reached the point where no more can be lobbed, but I hope my resilience and ability to cope continue (keep those fingers crossed for me).

I am also as stoic as they come, even from Yorkshire. Stoicism is also an interesting word as it relates to endurance and acceptance, without complaint or emotion. I am not saying I don’t complain or get emotional, more that I seem to have a deep acceptance of life events. This leads me to a place where I can be more resilient; I adjust and move on.

So, has Diabetes caused me to face events and situations that require me to be able to adjust but keep focussed on positives and move on? Absolutely, my attitude continues to be that there are many worse things I could have, although it’s tricky and can be rubbish. I am alive and have a good life; I consider myself to be lucky.

So how can we help people to become resilient?

How we react when things happen for me is key. I once had my driving licence revoked due to my diabetes. It was a mistake and I did regain it but not for many, many weeks. I was also quite heavily pregnant and still working at a hospital 15 miles away from home. My attitude? Public transport is what I need to do and I quickly learnt how to manage and still get to work. The buses were OK and I learnt to read and gaze at the views as we went on the long tortuous journeys (bus routes are rarely direct). I can still get myself around on public transport unlike my 85-year-old aunt who has never been on a service bus and now can’t drive. I feel sure I would have my walking stick and umbrella and be waiting for the free Sainsbury’s bus – I developed a skill! She choses not to learn to use the buses and complains that she can’t get out and about like she could. Choosing public transport over going off sick or leaving work maybe isn’t a big deal but it demonstrates my attitude.

Electing to react in a positive way to an event is for me the crucial factor. I am not saying I don’t gnash my teeth and wail but I soon move on actively seeking a way of managing past the problem. I can be stroppy, though, as I hate people feeling sorry for me so people saying how terrible it is can sometimes get short sharp words (sorry!).

So we can actively encourage people to focus on finding a way forward. For me my resilience is about taking a very active stance – if something around my Diabetes management is causing real difficulties how can I deal with it?

Can I learn more about it? Can I change my behaviour or how do I get to a better place? How can I find a way forward?

Having an effective network of people who can help me solve problems is also important, despite my independence. I like to talk problems through and it helps if its people who understand. This is how the Diabetes Online Community (#DOC) is helpful to me, a small network of people where I have reasonably strong ties – comrades in arms!  I can seek advice and support from these lovely people in addition to my own family and friends.

Creating peer relationships for people with LTCs might help some people, whether this be in person or online.

I like having things to look forward to and I feel this increases my resilience; setting goals, however small, helps me get past setbacks and put bad things that happen into an appropriate place in my life. I am a reasonably driven person and I always like to have something else in my life that can counter balance my health. Right now, for example, we are planning my husband’s 60^th birthday party, we are determined to make it special and memorable and are having great fun doing so! It doesn’t have to be big grand goals that distract you (there are always cats and kittens).

So how can we help people to set goals and take positive action. What one thing each day will help them feel that they are in control?

I recently spoke to a group of Paediatricians who care for children with Diabetes and this made me reflect.  It seems to me that we might want to protect young people and try to shield them from life events that challenge them but I think it is vital that they find out how they will cope and build and strengthen their personal resilience. Wrapping children in cotton wool when they have to face a lifetime of coping seems to me to be wrong.

There are of course other strategies I could use. I am not particularly good at looking after myself. I work too hard, rarely stopping and I’m not very good at relaxing. I think I need to learn these skills as I get older. I have tried mindfulness but I seem to be too busy to fit it in!!  I need to practice more!

I found this information from the American Psychological Association to be very helpful when reflecting on my own resilience.

This picture was taken around the time I was diagnosed as having T1 Diabetes

A guest blog from a friend.  Its a long one, much longer than my usual, but worth a read. For health care staff listen carefully. For those who have got caught in the care system read to see helpful insights and perhaps feel less alone:

Thank you to Anne for inviting me to blog as a guest. I write this blog with more than a little encouragement from several people but in particular from Anne. Anne tells me my experience has changed me and there is value in sharing this change of understanding with others.  My blog is written to share my experience from my perspective, the intention is to support understanding and learning. Some of my experience did not match up to my expectations but it is not my intention to cause discomfort or harm to those involved I wish to create learning and change. I have made the decision to remain anonymous in order to maintain the anonymity of my service providers.

So here is my story. How does it feel to have your whole belief system questioned? No, not questioned, that’s way too mild a description – wiped out. Yes, wiped out. Everything I knew about myself, in particular my 28 years of dedication to the nursing profession, suddenly no longer served me. An unexpected cancer diagnosis turned my world upside down. I had a pretty standard life up to then; busy daughter, sister, wife, mum and nurse. I was proud of what I had achieved and felt successful in my career having moved into a more senior position.

At the outset of my career, in the acute setting, my work was aligned to the medical model. I was unaware of any other way. This approach influenced me not only professionally but also as a person; it resulted in me favouring scientific approaches and controlled interventions. This came to fruition through the delivery of my 2 children by caesarean section, both for legitimate medical reasons but inside I was hoping this would be the method of delivery.

Seven years into my career I moved into the community, working in a very different model. A model which sought to educate individuals and develop attitudes which enabled them to take responsibility for their own wellbeing. The focus changed from illness to health and overall wellbeing.  It was my first exposure to the term ‘holistic’.

My career unfolded to promote prevention and empowerment. I have been fortunate to work for much of my time with children and young people. For me, this has created unique opportunities for me to learn how to work in the context of other’s lives. To work to understand what can be the best for that young person in their current circumstances, to see beyond the “patient” and deliver what I considered to be holistic care.

Throughout my time in nursing I have been supported to learn and develop through a range of approaches. The most significant include being exposed to a range of models of health and well-being; working in partnership with colleagues from education. I have learnt about their culture being introduced to motivational interviewing techniques and the maximising independence agenda and participating in an intensive leadership fellowship where I gained an understanding of difference and learnt to value it as well as insight into system leadership. I value and have gained immensely from all opportunities to learn – by far my biggest learning has been through my cancer diagnosis.

Everything I expected a “patient” experience to be seemed absent from my pathway. I was in a place of terror, facing huge overwhelming fear. Facing my own mortality. Wanting to understand every detail. Wanting to question every action. All of a sudden the “patient” was more important than they had ever been. The “patient” was ME, me the daughter, sister, wife, mum and nurse. It felt like cancer was taking over, I was losing my identity. My whole being was disintegrating. I longed to feel the familiarity of my pre-cancer life, but it was not to be. I had a brief encounter with thoughts of suicide until I recognised that it was in fact death I was trying to run from. I desperately reached out to everyone I knew, relatives, colleagues, non NHS practitioners and friends, to whom I am extremely grateful. They have all helped me understand, process, express and work out what I needed to do. They have helped me to represent myself, gain self-belief and understand my self-worth. Ironically the bread and butter of my work with young people.

One of the huge gaps for me in the cancer pathway was/is emotional support. The journey is a very lonely one and the time available in the NHS to offer any emotional support is limited. I developed my own network. I accessed charitable support, luckily for me, one particular provision is commissioned through NHS funds in my area. In my experience The Haven Breast Cancer Charity and The Penny Brohn Centre fulfil some of needs left unaddressed through the cancer pathway. I started to build a team of therapists around me including non NHS practitioners. This was soon after I came to appreciate the NHS pathway only had the capacity to manage symptoms, deal with the lump and any roaming cells. My understanding of holistic was so much broader than this.  Holistic in a physical sense, holistic in an emotional and spiritual sense, holistic in a nutritional sense and holistic in the context of my whole life.

I am very grateful for aspects of the NHS pathway to help sort out what the problem was, and manage the symptoms, in most cases the staff did their very best to give me what the system deems as the right experience. It came as a surprise that this wasn’t what I wanted or needed. I wanted an individualised approach based on me and the system doesn’t easily allow for deviation from a standard. The targets don’t allow it. I now appreciate that targets create inflexibility which seems very ironic when the focus of NHS care is promoted as individualised.

Some of the challenges/learning I have identified:

• Having a strong belief in the NHS, being proud of my role and contributions and now feeling conflict with this.
• Not being informed of any risks associated with any of the investigations it was assumed I would accept.
• Waiting nearly 2 hours past my appointment time to go into the consultation to receive my results.
• Being sat down immediately after becoming aware I had cancer to spend what seemed like an age having an anatomy and physiology lesson on the breast. My brain was in total shock and I struggled to concentrate. I sat behind a fixed mask behaving as I thought I should. I wanted to run, run and run and hug my children hard.
• Following my results having to walk back towards all the patients in the waiting room waiting to go in. Feeling so vulnerable and everyone’s eyes focussing my way. I wished I could leave by the fire exit.
• Being denied the opportunity to attend the discussion of my case at the multi disciplinary team meeting despite asking. “No decision about me without me”. Being told this was due to confidentiality and time. When I asked who would represent my concerns and expectations, being told the nurse would advocate on my behalf. Not understanding how she could do that when the final reports from investigations were being presented at the meeting and, therefore, I wouldn’t have seen them. I wasn’t sure what my thoughts were without hearing the options so I found it difficult to understand how she could represent me.
• Being pressured to conform to the target driven time line set by the government. In fact being phoned and asked to attend a consultation with the nurse the same day (Friday) as she called. In response to this I asked if I could attend first thing on the Monday so my husband could be present. The response was that the nurse would have to check with the ‘tracking lady’ (who managed the targets) before agreeing to it, as I might be breaching ‘my timeline’!
• Not ever hearing any words that gave positivity or hope in my NHS appointments. Feeling doomed.
• Feeling that some of the different departments seem disconnected from my overall pathway, just a process to produce a report.
• Being expected to have surgery without any pre-surgery consultation with the chap who holds the knife.
• Receiving an automated text “don’t forget to attend your appt on….” At this point I wasn’t yet aware what my surgery would be, let alone when it would be, and this text turned out to be the reminder for my surgery.
• Attending 2 different departments, both needing to insert needles into veins for different reasons. Wondering why this couldn’t all be done in one insertion to half the infection risk.
• Being supported to develop enough self-worth to realise I was so important that I could take control. Up to that point I had gone with the flow and felt I had to do as I was told.
• Gaining enough confidence to move provider service. My natural instinct is to be grateful for what you are given and not question it.
• Being told vitamins and supplements are insignificant. And then recently learning that Public Health England now recommend one of them.
• Researching information beyond NICE. Wanting to seek information from people who had lived this kind of experience. Understand it from the horse’s mouth not just the worker. You might like to check out the list below for just a few examples of the information I explored
  • Radical Remission http://www.radicalremission.com/
  • Canceractive http://www.canceractive.com/
  • The Care Oncology Clinic http://careoncologyclinic.com/
  • Liz Butler http://www.bodysoulnutrition.co.uk/author/liz/
  • Dr Kate James http://www.drkatejames.com/
  • Fiona Shakeela Burns http://www.canceractive.com/cancer-active-page-link.aspx?n=3430
  • Andrew Scarborough http://mybraincancerstory.blogspot.co.uk/
  • Jane McLelland http://wiseuptohealth.com/cancer-hope-this-could-be-a-game-changer/
  • Sophie Sabbage https://www.sophiesabbage.com/
• Developing a realisation that my body is my own. And I have the right to decide what happens to it. I agreed to have a wide local excision of the lump.
• Asking for copies of all my reports and results so I could process the information in line with my capacity to digest it.
• Feeling completely exhausted with researching and processing information because I believe there is more to disease and wellness than drug based statistics.
• Feeling intuitively that damaging my immune system through chemotherapy was not the right choice at this time for me. This being reinforced when I asked how much benefit going through chemo would add. I was told that the statistical prediction through the online tool was that chemo would give a 4.6% increased survival rate over 5 years. Wondering why we (the NHS) are prescribing such expensive and toxic courses of treatment based on such low improved outcomes.
• Gaining an understanding that the impact of stress on the function of your body is key to any potential for recovery. Understanding the evidence in relation to links between emotional and physical wellbeing. Actively utilising strategies to minimise negative thoughts and stress.
  • Joe Dispenza http://www.drjoedispenza.com/index.php?page_id=about
  • Dr David Hamilton http://drdavidhamilton.com/the-amazing-power-of-the-placebo/
  • Headspace https://www.headspace.com/signup?utm_source=google-b&utm_medium=cpc&utm_campaign=UK&utm_content=headspace&origintoken=google-b&gclid=CPaUz9jp0M4CFWgz0wodoH4HAA
• Receiving letters from the consultants expressing concern at me not taking active treatment, further filling me with fear and stress.
• An appreciation that a significant part of my contact with the NHS as “patient” creates me stress and anxiety from sitting in the waiting room with people clearly much worse off than myself, to the challenges I felt trying to represent myself in consultations. It is a relief to only have to attend once a year now.
• Feeling like my contribution to the whole scenario was gate crashing my pathway.
• Sensing an unintentional arrogance in relation to defining my care plan.
• Sensing an unintentional arrogance in relation to believing the NHS team was the only valid contribution to my care.
• Having my “holistic” approach to my care unintentionally undermined.
• Being bombarded with “think differently” messages in my role and continuing professional development. “Thinking differently” being seen as holding the potential to transform the NHS into something sustainable.
  • The Epigenetics Revolution http://www.nessacarey.co.uk/
• Having “question everything” engrained through your very being as part of your professional development. Being encouraged to question why systems operate the way they do, why care is presented as it is, whether we can do anything differently to improve efficiency, safety and/or experience.
  • Dr Aseem Malhotra http://doctoraseem.com/
  • Dr David Unwin http://www.diabetes.co.uk/blog/2015/08/dr-david-unwin-publishes-more-evidence-of-low-carb-diet-benefits-in-the-bmj/
  • Dr Margaret McCartney http://margaretmccartney.com/welcome/
• Realising the extent of influence and bias within medical research. See Ben Goldacre http://www.badscience.net/about-dr-ben-goldacre/ . And presentation by Peter Wilmshirst. https://m.youtube.com/watch?v=fLZ0sHOu8dE
• Learning there is a commercial agenda that may not always be in the best interests of individuals.
• Learning that some of the things I wanted to include in my wellbeing plan (that were being dismissed by my NHS team) are routinely included in other countries.
• Learning that the Switzerland Mammogram Programme is being phased out. http://www.nejm.org/doi/full/10.1056/NEJMp1401875#t=article
• Listening to the BBC radio 4 debate on breast screening http://www.bbc.co.uk/programmes/b049828q
• Being told your only method of monitoring is mammogram, when it only identified less than half the original tumour (as did MRI and USS). Appreciating the evidence that mammograms are not without risk, but being told there is no evidence they cause harm when I question having one.
• Appreciating that no one method of monitoring/screening is 100% effective. Learning of many different forms of monitoring, most not acknowledged by the NHS.
• Learning there is a Political agenda which may not always be in the best interests of individuals.
  • See The Promise Trailer http://medscans.co.uk/
  • Gary Fettke Orthopaedic Surgeon being stopped from giving nutritional advice even though his advice is helping clients. Gary Fettke No Fructose http://www.nofructose.com/gary-fettke/
• Learning the positive impact of exercise but being disappointed at it never being mentioned during my NHS contact. http://www.ncsi.org.uk/wp-content/uploads/Living-with-and-beyond-2013.pdf (page 9 second point down).
• Being declined a less risky/damaging USS as follow up because it doesn’t fit with the NICE pathway.
• Learning how old the NHS Cancer Act is. Considering when we produce academic work anything 3-5 years old is considered old unless highly significant. The Cancer Act is dated 1939.
• Learning of chemo sensitivity testing for breast cancer. At a cost of £3k individuals can choose to have the sensitivity of their tumour to different chemotherapies tested. The outcome can show some chemotherapies to be more appropriate than others, in some cases it shows that chemotherapy adds no therapeutic value. As a patient I want to know this information to help me make a self-identified choice. I would prefer to avoid the physical and emotional trauma of chemo given a choice. The NHS claim to require cost savings and efficiencies as demand is out weighing capacity. As an NHS worker I want to know why we don’t utilise this test prior to prescribing chemotherapy, to save costs on administering when it may add no therapeutic value and in fact may cause harm.
• Acknowledging a stark contrast in experience at NHS appointments and non-mainstream support. Gaining feelings of hope, positivity, human connection, control, progress, opportunities and being supported and growing as a whole person from the non-mainstream connections. Looking forward to these appointments which ranged from Reiki, Spiritual Healing, Homeopathy, Occupational Health Counselling, Nutritional Support, Chinese Medicine, energy healing, Yoga and Spiritual Work. All of which are entirely individualised and underpinned by building a relationship and connection with the therapist. This aligned to my values and expectations.
• Gaining an experiential appreciation that chronic illness is very different from acute where often working with cause and effect supports achieving an excellent outcome. Chronic illness is so much more complex and cannot be effectively addressed with the same approach.
• As parting words being told that “in my experience people who take an alternative route do not have good outcomes” without any clarification of what defines a good outcome. Feeling the treatment I had undergone was not worthy.
• Appreciating the NHS team involved in my surgery. They did a fantastic job in relation to the aspects of my holistic plan that they had the skills, experience and capacity to deliver. They were respectful, kind and caring within the context of their training and pathways.
• Recognising that the relationship with a practitioner is fundamental to achieving a positive outcome. I would increase the 6Cs to 8Cs https://www.england.nhs.uk/wp-content/uploads/2012/12/6c-a5-leaflet.pdf . Continuity and connection are key to success.
• Reinforcement of my belief that life is about art as well as science, process as well as product and quality as well as quantity.
• Living out the words presented to me at the start of my leadership fellowship “anyone who is not me is different” and appreciating the impact that difference has on experience and outcome.
• Wondering if we have got it all wrong?

So when, during my nurse training in 1986, I learnt that health was not merely the absence of disease little did I appreciate the significance this would hold for me. I continue to work through the conflict my experience has created. I am a keen ambassador of the NHS, particularly in acute and emergency care I feel we deliver outstanding outcomes. In relation to chronic illness though I feel we have much to learn and should open our hearts and minds to self-identified needs and working in partnership with a range of approaches which support living well, be they medical or alternative. Self-identified benefit is of equal importance to statistical outcomes when I am the patient.

I would like to thank each individual (of which there are too many to list) who has played a part in supporting me since my cancer diagnosis. I value every one of you for the unique part you play in my life.

I was watching the Florence Nightingale Conference 2016 remotely last week and I was delighted to see Jos de Blok., the CEO of Buurtzorg on the platform describing the evolution of Buurtzorg neighbourhood nursing service – he never fails to impress and his charismatic leadership shines through his presentations. As a Florence Nightingale Scholar I was privileged to actually visit Buurtzorg and go out on visits with a nurse and I have blogged about that experience here.

What struck me again last week was the question I keep getting asked – ‘Why can’t we do it like Buurtzorg here in England?’

When we visited the Netherlands I remember someone asking Jos what, in his opinion, was the biggest challenge in the UK to implementing a similar model to Buurtzorg. His response? ‘You are a brownfield site.’

Brownfield is a term used in urban planning to describe land previously used for industrial purposes or some commercial uses. Such land may have been contaminated with hazardous waste or pollution or is feared to be so.

Brownfield land – Wikipedia, the free encyclopedia

For those of you who are unsure what his meaning was the term brownfield site is used in planning terms to refer to a site that has already been developed, in contrast to a greenfield site where there is no existing development.

The same terms are also used in software development and deployment, where the presence of existing systems makes the transfer across to a new system more complex; there are legacy systems to consider and potentially old networks, boxes and wires to deal with moving from old to new.

When Jos set up Buurtzorg he didn’t have to worry about any of those things. He was able to start small and build and set up everything from new. He was able to learn and test the approach as he went along and could make decisions about how fast to develop without dealing with a concern about maintaining a nursing service to existing patients.

So the answer to the question ‘Why can’t we do it like Buurtzorg here in England?’ is a complex one. But here are some of the potential answers:

• We have an existing service to maintain to patients, uninterrupted and maintaining safety – the shift from here to there is seen as too risky;
• We have an organisational framework where there would be some people whose roles would no longer be required (similar to old boxes and wires). Middle managers don’t exist at Buurtzorg at all;
• The Buurtzorg model requires executives to cede power to frontline staff and to stop many of the management processes that underpin the way we currently work;
• It requires high trust and bravery from organisational leaders and commissioners – tearing up existing boxes and wires;
• It requires nurses to stop seeing the hierarchy as the way to be promoted and to focus on increasing satisfaction through self-development of clinical interests;
• The Buurtzorg model does not really have specialist roles and nursing seems to have increasingly become specialised in the last decades; Is nursing up for that?
• Meeting regulatory requirements would be possible in the Buurtzorg model through the use of technology. But who would dare to have an organisation with such a small amount of checking and performance managing?

Just a few of my thoughts. If I had the power though, I would have a go. The experience of visiting with the nurse I spent time with was unforgettable and reinforced for me the reasons why I went in to nursing in the first place – as Jos would say ‘doing what is normal’ and what is ‘common sense’.

You can watch Jos talk about Humanity above Bureaucracy here.  Listen to why he says he started Buurtzorg!

My guest blog for Dying Matters week on @GeorgeJulian ‘s blog

You only Die Once #YODO