A Yellow Wood by Gill Stanyard

The 1st June 2018 was my  last day as a  Non-Executive Director for NHS Dumfries and Galloway.  After four years of a potential eight year appointment from Scottish Government, I decided to  leave. I felt I had reached a good and fulfilling end and to stay on for another four year term would have been signing up to endure.  I made a decision I wanted to enjoy. So, I felt happy with my decision to end my time, made when swimming in a shimmering blue sea one early morning, whilst in Greece.

I made a decision. ‘Decision.’ The Latin origin of this word  literally means, “to cut off.” Making a decision is about “cutting off” choices – cutting you off from some other course of action. Now that may sound a little severe and limiting, it’s not. It is liberating. Decisions, they take us onto the next stepping stone, sometimes called  ‘The End’  – two words which tell us a story is over.

My friend made the final and shocking decision to end his life at the weekend. A fact I am still struggling to comprehend. Our last communication was a fortnight ago, with me texting him about all the different gins (24 to be exact) that were on the menu at my leaving ‘do.’  He texted me back with a  joke about Rhubarb gin. Then nothing. I didn’t think too much of it, life gets in the way. And then I received ‘The News.’  Yet I have forgotten a couple of times since then, and have gone to text him. Then, with a strange physical ‘flipflop’ stomach feeling,  I have remembered ‘The End,’ which is accompanied by much hurt and sorrow and  strangely, lines from one of my favourite poem’s. – ‘ The Road Not Taken.’ by Robert Frost:

Two roads diverged in a yellow wood,

And sorry I could not travel both

And be one traveler, long I stood

And looked down one as far as I could

To where it bent in the undergrowth;

 

Then took the other, as just as fair,

And having perhaps the better claim,

Because it was grassy and wanted wear;

Though as for that the passing there

Had worn them really about the same,

 

And both that morning equally lay

In leaves no step had trodden black.

Oh, I kept the first for another day!

Yet knowing how way leads on to way,

I doubted if I should ever come back.

 

I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.

 A single decision can transform a life. I always assumed Frost wrote this poem about himself, yet I recently read Hollis’s  biography of Welsh poet Edward Thomas, and discovered that Frost and Thomas were ‘besties.’  Frost had written the lines as a joke about Thomas’s depression induced indecision, which showed up on their long ‘walk and talk’ days together, with Thomas never being able to decide whether to take the path on the right or the left. When Frost sent the poem to Thomas, Thomas initially failed to realize that the poem was (mockingly) about him. Instead, he believed it was a serious reflection on the need for decisive action. At the age of 36, after much wrestling, Thomas felt compelled to enlist as a soldier in the Great War.

He wrote of his decision to his friend Robert Frost  “Last week I had screwed myself up to the point of believing I should come out to America & lecture if anyone wanted me to. But I have altered my mind. I am going to enlist on Wednesday if the doctor will pass me.”  On the first day of the battle at Arras, Easter Monday, 9 April 1917, Thomas was killed by a shell blast.  His poem ‘Adlestrop’ was published in the New Statesman three weeks after his death and has since become a classical favourite of British poetry.

Adlestrop

Yes, I remember Adlestrop —

The name, because one afternoon

Of heat the express-train drew up there

Unwontedly. It was late June.

 

The steam hissed. Someone cleared his throat.

No one left and no one came

On the bare platform. What I saw

Was Adlestrop — only the name

 

And willows, willow-herb, and grass,

And meadowsweet, and haycocks dry,

No whit less still and lonely fair

Than the high cloudlets in the sky.

 

And for that minute a blackbird sang

Close by, and round him, mistier,

Farther and farther, all the birds

Of Oxfordshire and Gloucestershire

Life sometimes makes decisions for us. I don’t mean to get all Dead Poet’s Society here, yet I think T.S Eliot had something when he wrote “What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.” (Four Quarters) We get ill and have to take time to rest and get well, and sometimes we don’t always recover, we have accidents,  we don’t get chosen for that job or by that person and we lose people and animals we love and care for.

Where possible, make a decision and choose your ending and make a new beginning, whether it be the end of an unhappy relationship and the start of a happier one with yourself,  saying No to working for extra hours, when you could be saying Yes to spending more time with your family, or your dog or your garden, standing up to a bully and choosing to start being assertive and courageous, speaking out against something which you see is wrong and thus ending corruption or collusion, stopping trying to do everything by yourself and start asking for help -(getting a mentor through NES really helped me with this)  and putting a stop to being taken for granted and drawing new boundaries that put your needs first.

I have taken a Non-Executive decision to be more accountable to myself in my life, to spend more time outside, to stop watching tv and read more poetry,  to save up to live in a place where I can have two donkeys, chickens and  another rescue dog and to track down some Rhubarb gin.

Sorry if I did not see you to say Goodbye. I wish you well in your decision making and hope that your sigh is a happy and fulfilled one.

I

What Matters to You: NHS at 70 by Kimberley McCole

As part of the ‘Summer of Celebrations’, we launched our campaign around ‘What Matters to You: NHS at 70’ on June 6^th.  Looking back of the past 70 years and into the future at the next 70 years how does this impact on what matters to you now?

Some thoughts we captured at a recent SPSP meeting:

We are looking for staff to collect their own thoughts and the thoughts of our service users using ‘leaves’ that will be used to build our ‘Experience Trees’.

For further information, or to request an ‘Experience Tree’ pack to use in your department, please contact: dumf-uhb.patientsafety@nhs.net

Experience trees will be featured in our September event.

Kimberley McCole is a Project Officer with the Patient Safety and Improvement Team at NHS Dumfries and Galloway

How do we stop people smoking at the front doors of our hospitals? by Chris Isles

Over a million smokers are treated in UK hospitals each year and a small proportion of these feel compelled to smoke when they are admitted to or visit hospitals. The image of smokers congregating at the front doors of our hospitals in wheelchairs with dripstands and catheter bags is all too familiar for those of us who walk past them as we come to work. We recognize that health risks to others are minimal because smoking in the open air is no threat to anyone’s health, but it nevertheless gives the wrong impression of a hospital as a promoter of a healthy lifestyle. We were particularly concerned that smokers would rapidly migrate to the front entrance of our new hospital in Dumfries when it opened in December last year.

A British Thoracic Society audit in 2016 of 14,750 patients across 146 hospitals in the UK found poor recording of smoking status in medical notes and little evidence that people who smoked were asked if they would like to stop smoking or were referred to a smoking cessation service. In hospitals with designated smoking areas (41% of all hospitals in the audit) smoking restriction was “completely or mostly” enforced outside these areas in only 33% cases. In hospitals with no designated smoking areas, restriction was “completely or mostly” enforced throughout the grounds in only 40% cases. This was despite a NICE guideline in 2013 recommending that hospitals should set out a clear time frame to establish or reinstate smokefree grounds and remove smoking shelters or other designated outdoor smoking areas.

As if in response, Public Health England launched a NHS Tobacco Free campaign in 2017, although the Department of Health in England has no plans to make smoking on hospital grounds illegal at present. Northern Ireland made it a criminal offence to smoke on hospital grounds in 2016. Similar legislation has been passed in Wales though here there is provision allowing the person in charge of the hospital to designate any area in the grounds as being an area in which smoking is to be permitted. In 2016, the Scottish Parliament passed an amendment to the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2005 which made it an offence to smoke within a designated perimeter around NHS hospital buildings. The proposed perimeter is 15 metres. Smoking within this perimeter will lead to a £50 statutory fine which can rise to up to £1,000 if taken to court. When this latest legislation is implemented in Summer 2018, environmental health officers employed by the local authority, rather than NHS staff, will hand out the £50 statutory fines. As it stands there are no exceptions, for example psychiatric hospitals or hospices. It will also be an offence to allow someone to smoke on hospital grounds with a maximum fine of £2,500.

An opposing view is that instead of criminalising smokers, we should show compassion for those who have the capacity to make an unwise decision and for whom smoking may be a comfort at a difficult time. We make allowances for drug users in hospital by prescribing methadone and we do not stop the morbidly overweight buying sugary drinks at the hospital shop, so why not allow smokers to smoke in a designated smoking shelter? The fact that Greater Glasgow Health Board failed to stop smokers from smoking at the front door of their hospitals, despite spending £473,500 on a high profile campaign in 2013, suggests to us that the money could be better spent addressing the findings of the BTS audit and by asking patients if they would like to stop smoking, referring those who do to a smoking cessation service, and by reinstating smoking shelters.

We could endorse the Scottish government’s proposed legislation that will attempt to eliminate smoking within a 15 metre perimeter of our hospitals or we could accept, however reluctantly, that smoking will never be completely eradicated and reinstate smoking shelters, while providing access to stop smoking services and support to help people who would like to quit. In any event it is difficult to imagine exactly how environmental health officers will impose and collect spot fines. And yes, as predicted smokers did rapidly migrate to the front entrance of our brand new hospital in Dumfries when it opened in December (see photo above).

Chris Isles is a Consultant Physician at NHS Dumfries and Galloway.

This blog was originally published in the BMJ online here

Dementia Awareness by Julie Garton

Dementia Awareness Week runs this year from 4 – 10 June. There are lots of events across the region supported by a wide range of individuals and organisations. This year, I’ll be promoting the use of a document called ‘This Is Me’ within acute hospitals and asking Dementia Champions and other colleagues across NHS Dumfries & Galloway settings to join in.

When someone with dementia comes into hospital, a care home or is receiving care at home, they and their family/friends may be asked if they have a ‘This is Me’ document.

What Is ‘This Is Me’?

‘This Is Me’ is intended for use by anybody with dementia, delirium or other communication impairment.

It aims to provide important personal information about the person from their perspective and those who know them best (family/caregiver) to help enhance the care and support given when the person is in an unfamiliar environment.  It’s crucial that we understand the person as an individual and take their personal history into account, helping us to communicate and engage with the person, which in turn can help us to prevent/alleviate stress and distress.

What are the benefits of ‘This Is Me’?

For the person, their families/caregivers – if the person with dementia has memory and/or communication problems, then a ‘This Is Me’ guides and supports staff to provide care in a way that respects the person’s choices, preferences and routines. ‘This Is Me’ can be a great opportunity to ask and find out information, that as family members we may not know – provoking good memories and conversation. In addition, a ‘This Is Me’ or similar may reassure people with dementia and their caregivers that we see behind the dementia and respect that person.

For staff – for professionals, it can help us deliver person centred care, and importantly, reduce the times we ask for the same information – the detective work has already been done.

Where can ‘This Is Me’ be used?

‘This Is Me’ can be used anywhere, in hospital, care homes, in primary care, respite care and is offered during Post Diagnostic Support.

When should it be completed?

‘This is Me’ always offered during Post Diagnostic Support but can be completed at any time.

Are there issues around confidentiality/sharing this document?

The document is the property of the person and/or their main care giver – it is not a clinical document and does not belong to any professional or service, the person/care giver decides what information is included and shared.

Once completed, the document should be kept in a place that is easily accessible for those providing care, for example, at the bedside, in a care plan. The information can help staff understand the persons’ baseline abilities, lifestyle, routines, likes/dislikes and gives great opportunities for conversation and engaging with the person.

What happens to the form if/when the person is discharged or transferred?

As it belongs to the person, it should go with them on discharge/transfer, and it’s also useful to check with the person and /or their main carer that the information remains up to date and relevant.

Living Well with Dementia

It’s important to understand that many people are able to live well with dementia, leading active and fulfilling lives for years after they first experience difficulties and receive a diagnosis, but coming into hospital can be daunting for all of us, and for people with dementia , this can be a frightening experience.

Whilst these days, a person with dementia may only be in hospital for a short time, how we communicate and support them will have an influence on the impact of the whole care experience and how quickly they can return home. We know that older people with dementia are more likely to be discharged to a care home than older people without dementia, have longer hospital stays and experience more falls and pressure ulcers.

We know that in Scotland around 93,000 people are living with dementia and we think around 25% of all acute hospital beds are occupied by people with dementia (Alzheimer’s Research UK, 2018), yet mostly, people arrive into our services without a document such as This is Me even if they have one at home.

“This is Me gives me golden information about an individual. The nuggets of information are priceless in helping to smooth the way to getting to know the person behind the dementia”

Gillian, Staff Nurse

‘This Is Me’ is just one of a range of tools that can support centred care, Getting to Know Me, Life Story work and a wide range of personal profile tools are available, many online, helping professionals to see the person, not just the patient.

I ‘m keen to hear about your experience/s of using This Is Me in your workplace – please contact me or, if  you would like more information about This is Me or would like a copy, please contact me at jgarton@nhs.net or 01387 246981.

Julie Garton, Alzheimer Scotland Dementia Nurse Consultant

Dietitians do Prevention by Laura King

Next week sees the return of Dietitians’ week and the theme this year is ‘Dietitians do Prevention’ with each day having sub-themes. Follow #DietitiansWeek on Twitter, Facebook and Instagram for some insights into our involvement in a wide and varied range of preventative activities.

Here in NHS D&G we have dietetic teams working across these areas which may come as surprise to the majority of folk working in the acute hospital who perhaps associate us mainly with artificial feeding and oral nutritional supplements for those who have scored 2 or more when nutritional screening is done on the wards.

As a small team we recognise that we have to play a role in educating and enabling patients, their families and carers to prevent over and under nutrition by supporting self-management, the dietitian can’t come shopping with you, cook your meals and help you to eat them and make the best choices, so we have to rely on using our communication skills to educate and inform patients and those close to them to help have a healthy, balanced diet that meets their needs.

We factor in ‘what matters to you’ and our assessments incorporate a huge range of factors as this poster illustrates:

Our Team works in the following areas all of which have significant roles to play in prevention:

Community Nutrition Support  (Kerry, Alexandra, Jackie, Jennifer, Lis, Dillon and Carole) – We provide practical, evidence based dietary advice, specifically tailored to each individual. Through dietary advice we aim to prevent and treat a wide range of medical conditions and empower people to make appropriate diet and lifestyle choices. Community Dietitians see patients in a variety of settings including community hospitals, nursing and residential homes, clinics and patient’s own homes. Our role identifies, prevents and manages malnutrition in the community. We liase with individuals to create realistic and achievable goals to optimise/improve their dietary intake.

Various medical conditions require an individual to be provided with their nutrition via a tube. We are responsible for managing these patients in the community, either in their own home or in a nursing home/community hospital setting.

We deliver educational talks on various topics including cardiac rehabilitation, stroke, Parkinsons disease and pulmonary rehabilitation.

Renal (Fiona) – Supporting patients with advanced kidney disease in managing complex nutritional requirements. Preventing further complications that can arise from inability to excrete electrolytes and fluid overload as well as avoiding weight and muscle loss for this group of patients who have increased requirements for protein once dialysis has commenced.

Gastro (Gemma and Sarah) – Preventing complications from poor management of coeliac disease such as the obvious GI disturbances through to the ‘hidden’ consequences such as increased risk of bowel cancer and oesteoporosis. Supporting patients living with inflammatory bowel disease to manage their symptoms and optimise their health and well being. Preventing the often crippling effects of irritable bowel syndrome by supporting patients to use the low FODMAP diet to identify trigger foods and modify their diets in a safe and sustainable way.  Preventing malnutrition in liver disease which is often masked by fluid shifts.

Paediatrics (Mhari, Anne and Tracey)  – Supporting parents & their child in managing children with complex needs, tube feeding, diabetes, gastroenterology issues, cystic fibrosis, weight management, faltering growth and allergies – preventing short and long term consequences of under nutrition.

Diabetes (Katy, Nicola, Sally, Sheena, Wendy): We are an integral part of the diabetes multi-disciplinary team providing a dynamic and evidence based service. We deliver quality assured education, and aim to support patient driven care and safe self management to those living with diabetes and their family. We also provide continuing education and support for health care professionals working with individuals with diabetes.

Weight Management (Katy, Nicola, Sally, Sheena, Wendy): We provide person centred, safe and evidence based advice to individuals with complex needs and requirements. This encompasses a variety of approaches to help aid weight loss and improve quality of life.

Mental Health and eating disorders (Sam and James) – Supporting recovery from mental health crises and from the consequences of living with disordered eating behaviours.

Catering (Debbie)- Working with Catering to achieve menus for inpatients across the region that offer a varied, balanced diet to support their recovery and prevent complications such as poor wound healing and  pressure ulcers. Also ensuring guidance for Catering teams to create therapeutic or special menus for patients’ individual dietary requirements. Training staff who make and deliver food, fluid and nutritional care to patients in hospital.

Acute (Laura, Anneka, Laura, Jennifer, Laura and Sheree) – seeing patients identified as being at risk of undernutrition to assess their individual needs and support recovery. Preventing increased length of stay, poor wound healing, pressure ulcers and other complications of malnutrition and providing advice for discharge to help patients stay well and continue their recovery once home with or without the support of the community dietitians as appropriate.

All this activity is coordinated and supported by our Head of Dietetics (Lorna).

The acute team are planning to pilot some staff education sessions on B3 and D7 to support ward staff in preventing malnutrition as well as identifying the patients who need our one-to-one support, so please get in touch with Dietetics on 01387 241568 if you would like to know more, want to arrange any training on your wards or if you have any questions about this blog post and what we do.

Meanwhile here are some pictures of the acute team (Anneka, Jennifer, Laura and Laura) ….

Laura King is Lead Acute Dietitian at Dumfries and Galloway Royal Infirmary