Global Surgery, Public Health and MDGs by @fanusdreyer

@fanusdreyer chairs the International Development Committee of ASGBI, is a member of Edinburgh University’s Global Health Academy and of the WHO’s Global Initiative on Essential and Emergency Surgery.

What is the primary care of obstructed labour, or a cleft lip, an imperforate anus or other birth defect? In the mid-1980s I worked in a small mission hospital at Nkhoma, Malawi as a medical officer. One day a boy was born with imperforate anus. It was the rainy season and there was no way he could be sent to the city. So I looked in the book how to do a defunctioning colostomy in a newborn, gave him ketamine and did the operation. Afterwards he stopped breathing every few minutes but started again when we flicked the soles of his feet. Our few incubators were all in use, each with three prem babies inside. So, over lunchtime and while the nurses kept our baby breathing, I built a wooden incubator, with plastic sheeting as a transparent top. That way we could give him oxygen, put two warm water bottles next to him and keep watch. I sat with our boy through the night, stroking him and flicking his soles so he would breathe, until the ketamine had worn off by the early hours of the next morning. He left hospital a few days later, ready to wait for the Canadian paediatric surgeon who was visiting a few months later. And I learnt that surgery can be primary care …

The declaration of Alma Ata (1978), which is a cornerstone of WHO healthcare states in section VII.3 that primary health care “includes at least: education concerning prevailing health problems,…maternal and child health care, …appropriate treatment of common diseases and injuries.” What place then for surgical conditions within “prevailing health problems”?

Of the global disease burden 11% needs surgery, mainly due to injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%) and peri-natal conditions (4%). Only 3.5% of 234 million annual surgical procedures worldwide are performed on the poorest 33% of people, but 80% of surgical deaths occur in low and middle income countries (LMICs). About 800 women die every day due to complications of pregnancy and childbirth e.g. obstructed labour, haemorrhage, sepsis, uncontrolled high blood pressure and unsafe abortion, i.e. mostly conditions that can be managed surgically. A significant complication for mothers who survive obstructed labour is obstetric fistula, which means that they are continually wet, smell badly and are ostracised by families and communities. With appropriate training fistulae can be repaired by non-doctors.

 

In non-communicable diseases (NCDs), the diseases of “rich countries” e.g. diabetes, vascular disease, hypertension and cancer, the highest incidences and mortality are in LMICs. The WHO expects 16million cancer deaths by 2020; 70% of these will occur in LMICs. Worldwide 5.8 million people die yearly from injuries, which is 32% more than from malaria, TB and HIV/AIDS combined. That means that 2300 children die daily from injuries. Road traffic crashes are responsible for 23% of all injury deaths, with 20 injured patients per fatality, reaching epidemic proportions in sub-Saharan Africa (50/100000 vehicles compared with 1.7/100000 in high income countries).

Household surveys in Rwanda and Sierra Leone have shown that the immediate surgical need is higher than the HIV rate, that 15-25% of respondents had a surgical need in the previous year that affected their ability to earn a living or their quality of life significantly, and that 25% of household deaths in the preceding year were due to surgical conditions.

 

The Millennium Development Goals (MDGs) have to report in 2015. At present there is a worldwide review of what global goals should replace the MDGs, with the WHO, the Gates Foundation and other philanthropic institutions all recently asking for submissions. The problem is that only MDG 1 (eradicating extreme poverty and hunger by >50%) is expected to be achieved worldwide by 2015. There has been some progress with MDGs 4, 5 (Child and Maternal Health) e.g. in Ethiopia through the work of community health workers, but in sub-Saharan Africa it might be that Rwanda is the only country to achieve all targets. The question can rightly be asked “Did the MDGs fail because these were drawn up in a room by rich countries for poor countries?”. For development to be real and sustainable it needs to be based on indigenous knowledge and solutions, not donor-led philanthropy.

What role then for global surgery after 2015? I have no doubt that the provision of safe and effective surgery should form part of the post-2015 development goals, and surgeons have a responsibility to contribute to this global debate. How can this be achieved? When we started our critical care teaching programme in Africa, now under the name of Alba CC Course Design, we first went to Hawassa in rural Ethiopia to teach health officers (non-doctors) who were doing an MSc course in emergency surgery. With funding from the Clinton-foundation they are taught to do 12 operations well and look after these patients; this covers 85-90% of surgical emergencies in rural Ethiopia e.g. Caesarean section, ectopic pregnancy, incarcerated hernia, debridement of open fracture. When I asked the first intake of students in Hawassa “Why are you doing this course?”, 6 of 8 answered “Because I have seen women in obstructed labour die”. When we went back for a second visit 18 months later, one of those same students had already done 70 Caesarean sections, under spinal, alone in theatre except for a midwife and a scrub nurse. Now that is public health worth fighting for.

Cost studies in surgery provision in Bangladesh and Sierra Leone have shown that the cost per disability life-year (DALY) averted is equivalent to the costs of a measles vaccination programme. Providing essential and emergency surgery saves more than it costs.

With various other groups we are proposing a programme called “15-by-15”, which will aim to teach 15 essential and emergency operations to the same minimum standard worldwide by 2015, to decrease the physical, psychological, social and economic burdens of untreated surgical disease in even the poorest communities. Everyone has “the right to heal” (http://vimeo.com/59388957).

(References available on request).

Next weeks blog will be by Penny Halliday, Non-Executive Director of NHS Dumfries and Galloway and is titled “Woman Interrupted”

Menopause in the workplace by Heather Currie

Women currently make up a huge proportion of the workforce; 47% of the workforce in the UK are women, of which 26% are currently over the age of 50. Women dominate (!) even more so in the NHS with 70% of the NHS workforce being female, of whom 26% are over the age of 50. This means that in the NHS there are currently 309,400 women over the age of 50.

 
With the average age of the menopause being 51 in the UK and the perimenopause often starting in the mid-40s, many of these women, of which I am one, are now experiencing the hormonal changes of the perimenopause and of the menopause. Consequently, demands of work can become even more challenging. Many women report great difficulties coping with what was previously manageable due to sleep disturbance and hence tiredness and, in some cases, exhaustion, difficulty concentrating, poor memory, low mood, lack of confidence, anxiety, joint aches, not to mention the embarrassment of the well- known hot flushes and sweats. Throw into this the demands from teenage children and elderly relatives and one might wonder how women cope at this stage at all!

The sad truth is that some really struggle and need help, yet often try to get through in the knowledge that for many, these symptoms will pass. The problem is that there is no way of predicting how long the “early” symptoms of estrogen deficiency of the menopause will last. Many women report sad tales of significant symptoms which they openly admit have affected their ability to do their job necessitating changes in their role, time off work and even early retirement. Not all have received appropriate support and there appears to be a lack of awareness of the impact that menopausal symptoms can have—“ isn’t it just about a few flushes?”!!

 
So what can we do? As a doctor working in the field of menopause, I would wish that all women could receive appropriate advice and information about the effects of estogen deficiency, what simple changes women can make to reduce symptoms and improve long term health and what specific treatments are available. Sadly this vision is a long way off but meanwhile, if symptoms are affecting you and your work, do seek help; ask your GP or Practice Nurse, make an appointment with Occupational Health, contact Sister Katrina Martin on our helpline, (01387241121, Thursdays 9am to 12noon), but above all, do not battle on alone!

 
See more information at www.menopausematters.co.uk and www.bladdermatters.co.uk or follow us on Twitter @menomatters

Heather Currie is an Associate Specialist in Obstetrics and Gynaecology in NHS Dumfries and Galloway

“I wish to register a complaint!” by @peterbryden1

So begins the famous Monty Python Dead Parrot Sketch. I am not a great fan of Monty Python myself as I simply don’t “get” some of it but, for those who are not familiar with this legendary sketch it is, whilst being completely off the wall and bizarre, very funny. It involves John Cleese trying to complain to pet shop owner Michael Palin, who has sold him a parrot which is in fact dead.

 
I was reminded of this lately and watched it on youtube. (Click here if you wish to do likewise) In reality this a humorous take on complaints handling at its worst, the service user wishing to raise a genuine concern and being “stone walled” by the service provider.

When I saw this again it made me think about how we handle complaints in the NHS, in particular in NHS D&G. I like to think that our Patient Services Team are a little more welcoming and receptive than Michael Palin and the outcomes for both the service user and staff are much better. The question is however, are we getting it right for our staff and the service user? In honesty the answer for both is most of the time – but I don’t think this is good enough and want to make this better. The challenge is that this is a very difficult area to always get things right for everyone, not least due to this being a very emotive and often personal subject. We are however constantly trying to improve what we do.

 
Feedback
I have to be clear that we deal with all forms of feedback from patients, families and carers: complaints, concerns, comments & compliments. We receive far more compliments than we do complaints. Recently we have focussed on improving our complaints process and therefore my focus in this blog relates to this.

 
As our processes for handling complaints continuously develop we must avoid becoming transactional, for instance simply focussing on ensuring we meet our 20 working day response deadline. Recognising this, we have started making changes to streamline our approach in a more person centred way. In any organisation where the business is working with and alongside people, I would observe that it is easy to forget that people are individuals each with different personalities and circumstances. In Ken’s recent blog he referred us to the “Empathy: Cleveland Clinic” clip available on youtube which perfectly illustrated this.

 
Immediate Contact
On receipt of a complaint or concern we have increased our contact by telephoning the person to discuss their issue in more detail. This way we are able to establish exactly what response they need; a face to face meeting, a full investigation, a written explanation or, if it is justified, simply just an apology. More importantly this discussion allows us to understand what the exact concerns are. What is written on paper is often not a good representation of what a person in really trying to say.

 
Since we have developed this approach we have been able to deal with a number of issues quickly and to everyone’s satisfaction. In some cases the service user is happy to have got things “off their chest” and for us to have simply acknowledged them. It is sometimes the case that a simple misunderstanding can be addressed straight away.

 
Patient Experience Group
To support our team and make improvements we have also created a Patient Experience Group which is chaired by Dr Ken Donaldson. This group consists of key members of the complaints team and clinical staff. A “Patient Experience Group” without independent representation on behalf of patients would be pointless and I am very pleased that our future meetings will be attended by our local Patient Advice & Support Service. The group’s role includes focussing on significant complaints and developing how we gather and share compliments. Most importantly we are discussing learning from feedback to ensure that this is fed back not just to the individuals involved but to similar areas that may benefit. This initial remit for the new group, which already feels very positive, will no doubt grow in due course.

 
From a personal perspective I have to be very honest in saying that in the last 3 years I have become a convert, not to theology, or worse from rugby to football, but in relation to complaints. I applied for and was successful in getting a job that was “dealing with complaints”. This has developed as I have moved on to work also with risk. Many colleagues see these role’s as very negative, one senior charge nurse (you know who you are) even refers to me as the “Grim Reaper” (I have thought about chasing him with a hoover so he can talk about Dyson with Death?). My conversion is in seeing that complaints are in fact normally very positive. I am now simply able to see that we identify learning from complaints to make positive improvements to our service. The difficulty is ensuring that these actually happen.

For those of us who deal with complaints on a daily basis it is disheartening to see how repetitive some issues can be. We see the same themes repeating themselves over and over again. I am sure that with our recent developments that we will see more of what makes my, and my colleague Yvonne’s, job worthwhile identifying learning and seeing it put in place to make a change.

 
To come back to where I started, my main message is that, as we develop our approach, our old methods of dealing with complaints and concerns have, like the parrott in John Cleese famous quote from the sketch, “Ceased to be”.

Peter Bryden – Patient Experience & Safety Facilitator Tel: 01387 241739 (Ext: 33739)

Our Enhanced Patient Experience Event will be on Friday 6th September at Easterbrook Hall. We need 20 teams of between 5 and 8 to take part from across NHS Dumfries and Galloway.

If you are interested please contact me on the above number or drop an email to:
dumf-uhb.EPE@nhs.net

Next week’s blog will be by Stephanie Mottram, Service Development Manager for Acute and Diagnostics, NHS Dumfries and Galloway.

Who is Molly Case…? By Alice Wilson

One of the fantastic but frightening things about social media is the ability to share information with lots of people very quickly – sometimes unintentionally. I suspect that Molly Case thought all she was doing was talking to colleagues at this year’s Royal College of Nursing Congress (a big enough adventure in itself for a 2nd year student nurse who was asked to share her thoughts with colleagues from across Britain). But since then, there has been a buzz about the You Tube clip of Molly’s talk and it was shown at the recent NHS Scotland event, generating much discussion about utilising it widely. Before you see and hear Molly for yourself let me tell you why I think it’s relevant.

In close to thirty years in nursing I have seen many changes in care and treatment but what hasn’t changed are the fundamental aspects of caring for an individual and their loved ones at a time of stress and crisis. No matter how technical nursing becomes, what people need to know is that someone cares about them, as an individual, and that leads me to a great debate which amazingly even now rages across and beyond nursing. Why do you need a degree to be a nurse?

I often hear people, including nurses, say that a degree is not what makes a good nurse. Of course, they are correct but having a degree doesn’t make you a “bad” or uncaring nurse. I will tell you why I think nurses do need it, despite being one of those people who, in the past, would have argued otherwise.

Our modern health care system health system demands technical clinical skills, informed decision-making, leadership and advocacy. The population has increasingly complex physical and mental health needs. Nurses are required to apply evidence based care and to demonstrate a level of critical and analytical thinking that was not expected in years past (the “good old days”). Then, nurses followed instruction, often without question, to administer medication and treatments simply because they were prescribed.

Thankfully, by the time I began my training, in 1983, we had begun to move away from that mind set. It was slow progress, not only amongst nurses but our medical and other colleagues had difficulty in accepting this shift and some still do. Ours was apprentice-style training, followed by what was often huge responsibility from early on in our careers. We became good clinical nurses and, in many cases, strong clinical leaders. We thrived on it. The truth, though, is that, unless we developed ourselves academically, there was little or no encouragement, until relatively recently, to pursue a route to degree level and beyond.

So…? What does that mean for today’s university trained nurses? Let me dispel a myth; student nurses still spend 50% of their training in clinical practice placements. More importantly, we are training nurses who have the skills to critically appraise what they see or what they measure and to use that information to make informed decisions about what to do next. Yes, they may lack some of the clinical skills we had on qualification. I guess the question is, though, whether you want a well prepared nurse with sound clinical knowledge who can pick up skills quickly; or someone who can carry out a task proficiently but doesn’t necessarily have the underlying understanding.

Let’s go back to Molly Case. In addition to the characteristics I have discussed, nurses have a fundamental role in ensuring compassion and empathy for people in their care. I am hopeful for the future of nursing when I meet our own staff and our local student nurses and when I hear Molly’s words in this clip, which you see by clicking here. She is responding to some of the criticism levelled at nursing; but look beyond that to her passion and then tell me that academic achievement and caring are mutually exclusive.

Alice Wilson is Associate Nurse Director at NHS Dumfries and Galloway

Next weeks blog will be by Peter Bryden, Risk, Feedback and Improvement Facilitator, and will be titled “I wish to register a complaint!”