I recognise that it is a bit cheeky of me to put my name to this as I haven’t written any of it. A few months back I was scrolling through Twitter and came upon this thread that really moved me. The messages are simple yet immensely powerful. I have therefore simply taken some screenshots from Twitter and published them here. As you can see this is by a Doctor called Alastair McAlpine who is a Palliative Paediatrician in Cape Town, South Africa. Read on…..
These high level national aspirations underpin much of the work that we, as healthcare professionals, are involved in delivering on a day to day basis. And achieving them does not start with children, the early years, or even pregnancy. It begins before conception. And I thoroughly believe that we are missing an opportunity. An opportunity which is inexpensive, evidence based and highly effective. That opportunity is better promotion of preconception health and care.
What is preconception health?
There is a clear link between a mother’s health before pregnancy and her baby’s health. We know that healthy women and men are more likely to have healthy babies who grow into healthy children 1. Therefore, thinking about, and improving, your health and wellbeing before conception increases your chances of a safe pregnancy, a thriving baby and a rewarding parenthood. Preconception is the safest and most effective time to prevent harm, promote health and reduce inequalities (pregnancy and birth outcomes are not as good for people living in the highest deprivation).
Currently, most people only consider two stages: avoiding pregnancy or being pregnant. With around 40% of all pregnancies being unplanned, the middle stage of preparing for the best possible pregnancy continues to be overlooked; in terms of policy, professional practice and individual thinking across Scotland. Where delaying pregnancy is the norm in Scotland (the average age of giving birth is 29.5 years, and 28 years for first time mothers), taking action to avoid pregnancy is not the same as preparing well for pregnancy.
Preconception health is about preparing for pregnancy, whether for your first pregnancy or your next pregnancy. What you do, or don’t do, before the pregnancy test says ‘yes you’re pregnant’ really matters. The choices you make and the actions you take before conception can make a big difference to you and your baby. That is true even if you haven’t given much thought to when you’d like to become a parent.
However, preconception health is not just for women, it is important for men too. There are steps that future fathers could take before creating a baby, for the sake of his own health and for that of his partner and their baby.
The infographic below, developed by Dr Jonathan Sher, an independent consultant and respected author of numerous published reports and blogs 2, identifies the steps women (and men, where relevant) should take to improve their preconception health:
Why promote preconception health?
Many things that may put your baby’s health at risk, such as smoking, drinking alcohol, taking drugs (prescribed or not), being overweight, being very stressed and some medical conditions, can all make an impact before you even know you are pregnant. That is why planning and preparing for pregnancy are so important.
However, not all the negative possibilities of pregnancy are inevitable. Many miscarriages, stillbirths, too early or too small babies, birth defects and other problems may be prevented and the odds of a good outcome can be improved. Good outcomes should not be left to luck alone. Doing what you can to become as healthy and ready as possible, and getting help if required, is hugely beneficial for yourself, your partner and your baby.
Traditionally, health promotion for pregnancy begins in the antenatal period, most often from first contact with Maternity Services at around 8 to 12 weeks of pregnancy. Many women are not aware that they are pregnant during the early weeks and months, and unfortunately it is not uncommon for women and men to continue negative health behaviours such as smoking and drinking alcohol through this important stage of early foetal development. Getting ready for pregnancy is as important as getting medical attention once you know you are pregnant.
The concept that “every contact is a health improvement opportunity” 3 demonstrates that all health and social care service providers who have contact with women and men of reproductive age can make a significant impact on optimising the preconception health of their service users. By utilising every opportunity to promote preconception health and to support women and men to make healthy lifestyle choices, the health and wellbeing of women and men who plan a pregnancy, as well as those who find themselves with an unintended pregnancy, can be maximised.
How can we incorporate preconception health into our work?
A new Preconception Health Toolkit that has been designed, tested and refined using Early Years Improvement Methodology will soon be available to support staff across all agencies to raise the issue of preconception health with their service users. The Toolkit includes information on risk indicators for adverse pregnancy outcome, health enhancing behaviours, tips for raising the issue and other suggestions for raising awareness.
The Preconception Health Toolkit will be launched next Friday 27th January at an event at the Garroch Training Centre near Dumfries, 10am-11.30am. Dr Jonathan Sher, independent consultant, will deliver an interactive key note address. There are still places available, please contact me at lauragibson1@nhs.net if you’d like to participate.
Following the formal launch, the Toolkit, which has been developed specifically for non-specialist staff, will be available electronically to all staff and volunteers in the statutory and third sectors. Please contact me to request a copy or download it from http://www.sexualhealthdg.co.uk.
Laura Gibson, Health and Wellbeing Specialist, DG Health and Wellbeing, Directorate of Public Health
References
1 Royal College of Obstetricians and Gynaecology (2008) Standards for Maternity Care Royal College of Obstetricians and Gynaecologists; London
2 J Sher (2016) Prepared for Pregnancy? NHS Greater Glasgow and Clyde (Public Health)
3 Woods, K (2008) CEL 14 Health Promoting Health Service: Action in Acute Care Settings The Scottish Government: Edinburgh
Not one of us has had a choice in the life circumstances into which we were born. We are born in a country, with particular parents and with certain advantages and possible disadvantages – and this can have a lifelong impact on our health and wellbeing. We know that some are born with genetic conditions that have a huge effect on their lives; those brought up in poor housing conditions are more likely to suffer from respiratory diseases; children brought up in care may have less resilience to overcome difficulties (which is not to say that many don’t overcome them); and many are not able to make the most of opportunities because of the difficult and challenging circumstances they find themselves in.
Within Public Health, a discipline that has a major focus on seeking to improve health and wellbeing at a population level and reducing inequalities, a model that we often use to describe these situations is the Dahlgren and Whitehead rainbow (below). This, since its publication, has become a frequently used model for describing the underlying causes of ill health in the population and provides a helpful framework on which much of the health improvement work we are involved in is based. It offers a social model, which focuses not just on the individual lifestyle factors that impact on health, but on the wider socio-economic, cultural and environmental conditions, which make a huge difference to our health and wellbeing.
Underlying these differing life circumstances are inequalities which may be income, education, housing, environment or social conditions. The graph below shows how health and social problems are worse in more unequal countries. These inequalities can be found with regards to child wellbeing, levels of mental illness, drug use, life expectancy, infant mortality, obesity, teenage pregnancy, education, to name just a few.
These inequalities are not inevitable, and therefore should be tackled in order to ensure people have opportunities to improve their health and wellbeing. It is the role of Public Health and all our other partners to address these issues. It is not an easy task nor can it be undertaken by one agency alone.
Improving health and wellbeing must be supported at all the different levels identified in the rainbow model above. At an individual level, we need to understand why people behave in the way they do. Much of our work in improving the populations’ health and in providing preventive services is about supporting people to make their own positive life choices. However, having the ability to make choices is something not everyone has to the same extent: the very reason why we need to support people. For example, at one level, people have the choice as to whether to smoke or not. But if you are under stress, giving up smoking might be one thing that is too difficult to contemplate: we know that will power is a finite resource, and if you are juggling with a crisis, then all your efforts need to go into solving that crisis. And that is not even considering the physical addiction and the impact of tobacco withdrawal. Remember, very few people actually want to be addicted to cigarettes.
Health and wellbeing also needs to be addressed at a family level. For example, we know that some children are disadvantaged at school entry because they do not have the necessary emotional, social and cognitive skills which enable them to take advantage of the opportunities available from education. Support for parents can provide the self-confidence and self-efficacy to help counteract these difficulties, so that children can have the best start in life. This is extremely important for future life when these children become adults, and affects further wellbeing and subsequent use of health and social care services.
There are many approaches to supporting improved outcomes for population health. For example, at a wider level it is important that environmental issues are addressed. Creating enough green space for children to play or adults to walk and be physically activity can have a major impact on health and wellbeing – as can having nutritious food available locally, or accessible social activities. Having enough money is also a key element of trying to live healthily. In times of job insecurity and rising costs, this can be challenging, so ensuring access to the right kind of advice for claiming benefit, offering support to complete job applications, provide welfare rights information to support people to claim what they are entitled to, providing accessible health services and health information which is easily understood, is vital.
If, as a society, we are to reduce the burden on health and social services, we must work together to prevent and mitigate against the circumstances which act together to limit the ability for communities and individuals to achieve optimum health and wellbeing. There is a lot that can be done to support people’s health and wellbeing, and this must be underpinned by looking at what people themselves really want, not just assuming that we, as health professionals, know what is best for them. We need to listen and understand where people are coming from, and do that with compassion. We all want the freedom and autonomy to do what is best for ourselves, and we need to make sure we support people in achieving that for themselves.
Catherine Mackereth is a Consultant in Public Health and Michele McCoy is a Consultant in Public Health and Interim Director of Public Health at NHS D&G
The Scottish Independent Advocacy Alliance (SIAA) has recently launched an animated film Opening Doors which shows the difference that independent advocacy can make to the lives of parents going through child protection procedures.
Opening Doors follows 3 characters, Laura a young woman with learning difficulties who is pregnant, Ahmed who has a young son and has issues with alcohol and Teresa who has mental health issues. It shows how Moira their advocate helps them know and understand their rights, navigate the system, ensure they are listened to and speak for themselves. The film was made with the help of a focus group made up of parents and advocates with experience of child protection procedures. The focus group helped identify the key issues and used their experience to highlight the difference advocacy makes. Members of the focus group met with the writer to inform the script and ensure that the language was clear and accessible they also met with the animator to ensure that scenes were realistic and that characters were portrayed positively.
The whole process of producing and launching the film was a collaboration with Media Co-op who have a track record of producing high quality, award winning films with a social message. They worked with us to recruit a professional writer, animator and cast of actors. The part of Laura was played by a woman with learning difficulties.
Intelligence we gathered indicated that advocates were increasingly being involved in advocating for parents with mental health issues, learning disabilities and substance misuse issues who were in danger of losing access to their children.
It’s not unusual for advocates to get involved in supporting people in various situations but the feedback we received showed there was a real need for advocates to know and properly understand the complexities of child protection.
The film is the culmination of our three year Families at Risk project funded by the Scottish Government Third Sector Early Intervention Fund which was administered by the Big Lottery. The initial project was designed to raise awareness about child protection issues amongst advocates and to inform social care professionals and children’s hearing panel members about independent advocacy. Phase 1 developed and delivered training specifically for advocates, providing grounding in key legislation and policy. Alongside this, guidelines for advocates working with Families at Risk were developed in consultation with advocacy organisations. The guidelines provide a useful reference to best practice in advocacy. They also are used by people using advocacy to get clarity about what they can expect from an advocate and for professionals who want to understand the advocacy role further.
Opening Doors was launched at the Glasgow Film Theatre with approximately 100 people in the audience. The showing was followed by a plenary session made up of representatives from Scottish Government, Children’s Hearings, an independent Safeguarder and an advocate. The discussion and questions from the audience raised interesting issues around how complex the child protection system is, how difficult parents find it to engage with and how disempowered they feel and crucially the difference support from an advocate can make for everyone involved even if the outcome isn’t what the parents are looking for.
We have received a great deal of positive feedback on the film and it has been viewed and promoted by a range of individuals and organisations across the UK.
Opening Doors will be used as part of training programmes for a range of professionals wanting to learn more about the difference advocacy can make in emotionally difficult and legally complex situations. The film is available in a number of different languages including; Arabic, Urdu, Punjabi, French, Polish and BSL (British Sign Language).
We know that there isn’t enough independent advocacy for people who have a statutory right to access it but we believe that in situations where decisions are made that have a long term and life changing impact then advocacy should be available. We believe that in the ideal world services would be person centred following a human rights based approach so that no one needed the support of an independent advocate but until that day arrives we believe that where families are going through child protection procedures then both parents and children should have access to separate advocates.
Some facts about independent advocacy in Scotland
Research carried out by the SIAA shows that during 2013-14 £11.3 million was spent on advocacy. There are advocacy organisations in every LA area in Scotland and during 2013-14 over 27,000 people accessed advocacy.
Find your local advocacy organisation through Find an Advocate on the SIAA website.
For more information about independent advocacy in Scotland visit www.siaa.org.uk or email us at enquiry@siaa.org.uk
Shaben Begum MBE is the Director of the Scottish Independent Advocacy Alliance
10th of March 2016 is World Kidney Day. Many activities take place around the world to raise awareness of risk factors for kidney disease, encourage systematic screening for high risk groups, encourage transplantation and advocacy of governments to take action and invest further in screening and treatment. Despite these efforts especially by organisations like World Health Organization (WHO) and International Society of Nephrology (ISN) we are still not equal in terms of access to treatment.
Sharing my own experience would perhaps shed more light on this. Having done my initial training in general medicine in Sri Lanka I came to the point where I had to undertake further post graduate studies in a subspecialty in Medicine. When I picked renal medicine, the common response from members of my family was “Are you sure?” Kidney disease outcomes were perceived as being worse than cancer due to limited access to dialysis. When I started my training in 2010 there were only 90 functioning haemodialysis machines in government hospitals in Sri Lanka for a population of 20 million (estimated prevalence of Chronic Kidney Disease (CKD) between 4-8%). Haemodialysis had been first introduced to the country in 1983 and attempts to introduce Chronic Ambulatory Peritoneal Dialysis (CAPD) had not been successful as the cost was much greater than the cost of in centre haemodialysis given that no plants for PD fluid production were in the region. Live donor transplantation was an available option but limited by long waiting lists in the government sector and availability of donors. I went through my training attending on patients who would present breathless with fluid overload due to ad hoc haemodialysis. The limited dialysis slots had to be prioritised according to the severity of symptoms. When I came over to the UK to complete my training in nephrology I was amazed by the free and unlimited access to renal replacement therapy. What was more they were transported back and forth from the dialysis centre at no personal cost!
On my return to Sri Lanka in 2013, to take up my first job as a consultant I was hit hard by the reality. I was appointed to be the only nephrologist in the southern province of the country to provide care for a 2 million population. I was to be based in the tertiary care centre in the region with 7 haemodialysis machines and facilities to perform a live donor transplant every fortnight. I also had funds to have a further 10 patients on CAPD. The hemodialysis machines were working around the clock and at any given time a couple of machines would be having technical faults leaving me with five functional machines at a given time. The total number of patients registered in the clinic was just above 1000 (at least 150 end stage renal disease requiring dialysis) and there would at least be another 5 to 8 in patients requiring dialysis in the hospital. The way I could prioritise was to give preference to the patients with acute kidney injury (with the hope they would recover) and those awaiting live donor transplantation. Everyone else who did not have a plan but were in end stage renal failure had to be fitted in to the left over slots. Despite our best efforts many patients lost their lives due to inadequate dialysis.
That is the heart sinking story of kidney disease in the developing world. 80 % of the dialysis population is in Europe, North America and Japan while the rest of the 20 % is distributed in the vast regions of South America and Asia. These figures are a reflection that dialysis is a luxury mostly the rich can afford. Though disparities in renal care are greater in the developing world, there is data to support inequalities in provision of care to the more disadvantaged populations in developed countries. For example, in the United States ethnic minorities have a higher incidence of end stage renal failure while in Australia figures show that aboriginal Australians are 4 times more likely to die of CKD than the non indigenous Australians.
Concerted effort on prevention and early detection would be the way forward to minimise these disparities in the future. World kidney day is a global awareness campaign that aims to do just that. This year the theme is “kidney disease and children – act early to prevent it” and aims to highlight the importance of protecting kidneys from an early age. We hope to have a booth in DGRI on 10th March to hand out leaflets and badges to join in this world wide effort of raising awareness of kidney disease. We hope that staff as well as visitors will take the time to come visit us and support the world kidney day initiative.
Dr Nadeeka Rathnamalala is a Locum Consultant Nephrologist at NHS Dumfries and Galloway
The use of general anaesthetic for extraction of children’s teeth has reduced very considerably in Scotland in the past 20 years – quite right too, I’m sure most people would agree.
The Scottish government has arguably led the world in funding the Childsmile programme, which is intended to tackle the fundamental causes of poor oral health in children as early as possible, by providing multiple educational and preventative interventions in community and school settings.
Like most large scale health programmes and initiatives these days, it is accompanied by HEAT targets, one of which is for a reduction in the number of elective hospital admissions for tooth extractions for children aged under 3 years.
All very sensible and intuitive, and given the scale of the funding associated with Childsmile, it is hardly surprising that the impact on oral health should be monitored over time to see if the various initiatives have been effective. It would be fair to say that dental public health experts worldwide are interested in the long term success or otherwise of Scotland’s Childsmile project, to see if they should commissioning or implementing something similar. Changing people’s behaviours as opposed to increasing their levels of knowledge is notoriously difficult; looking back on issues such as smoking and drink-driving, we all know that changes have gradually occurred, but they have taken decades of health education and health promotion effort to bring about.
The much improved access to dental care across D&G region since the mid-noughties, combined with the Childsmile activities by dental primary care and health improvement teams have been very successful in identifying those families most at risk of poor oral health. And we are much more successful than previously at providing appropriate dental treatment for young children with active tooth decay.
So paradoxically, the average age of many children’s first contact with a dentist has almost certainly come down, as many families now register with a dental practice for care. And the numbers of children aged 3-5 years being admitted to hospital for tooth extractions under general anaesthetic has certainly come down since 2003 rather than gone up, as the graph shows.
Chart 1 – DGRI Hospital admissions for tooth extractions in children aged 0-5 years old in 2004, 2009, 2013, and 2014
But as you can see, the actual numbers of children under three admitted for tooth extraction are very low – only a couple a year on average. And some of these need an extraction because of trauma i.e. an accidental fall has damaged their front teeth, rather than tooth decay. And the average numbers admitted per annum have not really come down since 2009.
Very young children with painful tooth decay often now have much earlier contact with healthcare staff who successfully identify that they have dental treatment needs.
And those children for whom a tooth extraction is genuinely required, which can usually only be achieved by admission to hospital and use of a general anaesthetic, are arguably now more likely to get referred promptly.
If the whole point of HEAT targets from a government perspective is that ‘what gets measured is what gets done….‘ , where does that leave us when it comes to trying to achieve this particular target?
One way to achieve the HEAT target would be to leave the waiting times for admission long – children might be under three years old at the time of the decision to extract the tooth, but even with 18 week waiting time guarantees, most of them will be over three years old by the date of admission. Should we postpone provision of treatment in hospital for young children needing tooth extractions, because it would help us achieve the HEAT target? I don’t think anyone would advocate that, but could failure to achieve the reductions in numbers of hospital admissions be used to imply that oral health is not improving in Dumfries & Galloway region? Or NHS Dumfries & Galloway is not implementing the Childsmile programme properly?
We have already created local care pathways to ensure that the alternatives to extractions of deciduous teeth are available for young children, including active dental prevention strategies, and provision of more specialised paediatric dental treatment services. And because the risk associated with the use of general anaesthetic is very much higher than for routine dental treatment, dental general anaesthetic services are delivered in accordance with all of the currently available clinical guidelines, in as safe an environment as we can achieve.
I think it was Winston Churchill who talked about ‘lies, damned lies and statistics…’ and looking at the available figures general anaesthetics for dental extractions in children and Dumfries & Galloway over a period of years is pretty complicated. You can make an analysis of the statistics apparently illustrate almost anything you like.
Chart 2 below shows child admissions for general anaesthetic for dental extractions across Dumfries & Galloway region by quarter for 2013-14, arranged by age group.
I could certainly argue for hours about what the figures and any mapping of overall trend does or does not tell us, based on this.
I’m sure that the original intent of the HEAT target was to see if oral health in very young children improves over time, particularly as it is well-known that children with complex physical, medical and social needs are at much higher risk of developing tooth decay. One can also assume it was intended to ensure that health authorities commissioned adequate local primary care dental services for families with young children.
But HEAT targets are very high-profile reporting measures, and failure to achieve them can very easily be misinterpreted, even by people who are entirely sincere and well-intentioned. Whatever the reasoning behind it, this one could become an unfortunate example of the misuse or misinterpretation of statistics.
Penny McWilliams is Director of Primary Care Dental Services for NHS Dumfires and Galloway
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