Health and wellbeing – How do we get it right? by Catherine Mackereth and Michelle McCoy

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.

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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.

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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

 

Gender Matters by Lynsey Fitzpatrick

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image5On 6th September 2016 in Lockerbie Town Hall, NHS Dumfries and Galloway and Dumfries and Galloway Council, supported by the national feminist organisation ‘Engender’, jointly hosted ‘Gender Matters’ – an opportunity, in the form of a workshop, to explore the issues surrounding gender equality.

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There were over 40 people from a range of organisations including NHS, Council, South West Rape Crisis and Sexual Abuse Centre, LGBT Plus, LGBT Youth Scotland, DG Mental Health Association, Support in Mind and Glasgow University, and also members of the public along with staff from other Health Board areas.
When I started to write this blog post, I was thinking back as to why the steering group behind the event decided to host this event in the first place. There is a plethora of evidence to back up why we need to support events of this nature, for example:

  • Women are twice as dependant on social security than men
  • In 2015 the gender pay gap in Scotland was 14.8% (comparing men’s full time average hourly earnings with women’s full time average hourly earnings)
  • Also gender pay gap in Scotland when comparing men’s full time average hourly earnings with women’s part time hourly earnings was 33.5%
  • This means, on average, women in Scotland earn £175.30 per week less than men.
  • The objectification and sexualisation of women’s bodies across media platforms is so commonplace and widely accepted that it generally fails to resonate as an equality issue and contributes to the perception that women are somehow inferior to men.
  • Femininity is often sexualised and passive whereas masculinity is defined by dominance and sometimes aggression and violence.
  • At least 85,000 women are raped each year in the UK.
  • 1 billion women in the world will experience physical or sexual violence in their lifetime.
  • In 2014/15, there were 59,882 incidents of domestic abuse recorded by the Police in Scotland. 79% of these incidents involved a female ‘victim’ and male perpetrator.

 

So there are plenty of reasons as to why we held this event; to challenge social gender norms, to progress thinking around changing perceptions in our homes, at work and how we confront the media (not least our legal duty under the Equality Act 2010).

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But what is it that made us so passionate about being part of this work?
image12A huge reason for me personally is that I have an (almost) 5 year old daughter. In my current post as Equality Lead for NHS D&G I have become much more aware of some of the research and facts around gender equality and often reflect on how her future is being shaped as we speak; because of the gender norms all around her, expectations from her family, her peers and her school.
I’m horrified to think that she is more likely in later life to be paid less than a male counterpart for doing the same level of work, or that her relationships and self esteem will be impacted by the stereotyping of her gender in the media.

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image29A friend and I had a discussion at one of the film screenings for “16 days of action against Gender Based Violence” which focused on the sexualisation of children from an early age. We talked in particular detail following the film about the impact the internet might have on our daughters as they grow up – the availability of porn, more opportunity to be groomed, shifting expectations of how our bodies should look and what we should be doing with them – and decided that we really wanted to do something about this, to make a difference to our daughter’s lives, and hopefully many more at the same time.
As NHS employee’s we are legally obliged to consider gender issues in everything we do. The often dreaded impact assessment process is designed to help with this. Yet at times it is seems more of a burden than a way of informing services how best to prevent discrimination and advance equality for all.

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I came across the following clip at a Close the Gap event which shows how gender mainstreaming is applicable in situations that many of us deal with on a daily basis and how this can impact on efficiency and quality of public services, benefitting not only the people who use our services, but also our key partners:

(Watch from the beginning to 3:18minutes in for a quick demonstration on how indirect gender approaches can change the way people live).
Back to the event in September: the day was split into two halves – the morning session focused on Culture and the afternoon session on Economy. The format for the day was Open Space Workshops, starting with a short presentation on each of the topics. Participants then identified topics that their group wanted to focus their discussions around. Participants were free to move around the room and join in or leave discussions as desired.
Some of the topics covered during the course of the day included:

  • Gender in the Media
    Equal pay for equal work
    Rape Culture
    Part time Work
    ‘Hidden Care’ and the economic ‘value’ of care
    Societal Norms
    Women and Sport
    Success
    Cultural Expectations
    Being non-gender specific (e.g. clothes, toys, activities)
    Women’s Only Groups
    Gender Education
    Welfare Reform

Understanding ‘double standards’
There was a real buzz in the room as each of the groups discussed their topics of interest and it was clear that participants appreciated the opportunity to discuss the issues openly, an opportunity we don’t often get.
All of the event feedback was extremely positive, and there was a real interest from participants in taking this work forward, both in the workplace setting, and in their personal lives. Some of the suggestions included the creation of a Gender Equality Network for D&G, avoiding stereotyping, creating safe spaces for women to talk openly, promoting the White Ribbon Campaign, encouraging managers to see the benefits of a work/life balance, challenging the way gender is represented and considered across society, e.g. across social media, within policies and structures. This list is by no means exhaustive of everything that was covered on the day!
I hope that having a quick read of this sh

ort blog (and hopefully a watch of the gender mainstreaming clip) will be enough to convince a few more people that gender equality really does matter.
If you are interested in being part of future discussions on gender inequality and involved in a Women’s Network then please get in touch.

Lynsey Fitzpatrick is Equality and Diversity Lead at NHS Dumfries and Galloway

Thank you to Ward 18 and DGRI by Kevin Irving

Dear Mr Ace,

I am writing to you to express my sincere gratitude and thanks to the staff in Ward 18 (Elderly Care) of the Dumfries and Galloway Royal Infirmary. Whilst I was visiting the UK my Mother took critically ill and was admitted to the hospital where she received excellent care from the doctors and staff on this particular ward. I spent nearly 4 to 5 hours a day in the hospital for over 15 days attending my mother’s bedside and could observe the highest quality of care. Having worked in health and safety in my career as a mining engineer, at the most senior executive level, for over 35 years I can honestly comment that the leadership and team work on Ward 18 was some of the best I have seen and is a credit to the staff.

The doctors on the ward, from the lead consultant caring for my mother to the rest of the team, showed enormous care and compassion to my mother’s needs and requests. My mother made what I think we all would agree was a remarkable recovery. During the difficult time of when my mother was very ill the doctors ensured that both my sister and I were well informed and we were able to have very open and honest discussions regarding my mother’s care. They also showed compassion towards my sister and my own feelings through what was a very stressful period.

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I would like to give special thanks to Snr Charge Nurse Janice Cluckie who demonstrates incredible leadership to her staff and also discussed my mother’s needs with empathy and thoughtfulness. It was clear to see that she took time to see that all patients on her ward were well cared for. Janice is certainly a role model that your organisation should be proud of.

I have nothing but praise for the ward staff who showed consideration and care for all the patients. From a visitors point of view I saw total dedication to their duty for the well-being of their patients with humbleness and sincere kind heartedness.

Whilst spending time in the area I had the opportunity to look around the premises and surf the internet about the hospital. I see from your Board papers and Inspectors reports that you have some areas for improvement. I can only say from my observations that you certainly appear to be on a positive trend. I noted in your most recent Board papers that complaints about the hospital service are on the increase. I would recommend making a KPI of some of the positive comments you may be receiving, such as this letter, as they may show another side of the story or use information from the website www.patientopinion.org.uk or NHS Choices website.

As an aside I used the dining room daily at lunch times and the food served was of good healthy quality, a good price and presented by excellent welcoming staff. I feel the NHS food is sometimes often viewed negatively. I can only say that Dumfries and Galloway seem to be improving this aspect of patient and staff care.

I would be very grateful if you could ensure that the leadership team of Dumfries and Galloway Royal Infirmary give some recognition and positive feedback on my behalf to the doctors and staff on Ward 18.

With many thanks, yours sincerely

Kevin Irving

Kevin, who lives in Australia, added a handwritten post script which read “Wishing you all a Merry Christmas and a Happy New Year from the sunny side of Down Under.”

Three generations of surgeons, born in the wilderness by @fanusdreyer

Olifantshoek

Olifantshoek is a small town in the south-east corner of the Kalahari desert, in a “poort” where a seasonal river flows through. Seasons here are measured in years or decades, not months, but there is enough water so that the town dam only occasionally runs dry. In the Northern Cape and southern Namibia children regularly get to school age without ever having seen rain. In the 1920’s my grandfather was the Dutch Reformed minister in Olifantshoek.

One day in 1922 granddad travelled to Bloemfontein for the church synod. He was a bit of a technophile so he was one of the first in the region to own a car, although he did his parish visits on horseback due to the roughness of the terrain. After the synod he gave a lift home to a Rev Brink from Danielskuil, another small town on the edge of the Kalahari. They got to Danielskuil late afternoon, granddad was treated to an evening meal (the Brinks have always been superb cooks) and offered a bed for the night. He declined as his wife was nearing the end of her pregnancy and he wanted to get home that night. Rev Brink knew of a shortcut along farm roads but this had lots of gates to be opened and closed. He then offered that his six year old son could accompany Rev Dreyer, show him the shortcut and open and close the gates for him. Granddad gladly accepted and they got home by 1 am. And so it was that my future father-in-law helped my grandfather get home to my grandmother, who was expecting my father’s birth any day.

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Dad grew up during severe drought and the Runderpest in the 1920’s Great Depression; the only animals still alive in Olifantshoek were donkeys. It was so dry that grandma had to send a bottle round the streets; everyone who had a little bit of donkey milk to spare would put it in the bottle so she would have just enough to feed a future ground-breaking surgeon.

In the 1950s Dad helped to develop potassium cardioplegia for open-heart surgery while working with Sir Ian Aird, got married to Mum in Edinburgh with Dr Davidson (of the internal medicine textbook) as best man, then went back to Cape Town where in 1958 he did the first technical successful heart transplant in the laboratory by swapping two dogs’ hearts; they lived three days until rejection set in. He was invited to join Dr Willem Kolff (who had built the first dialysis machine) in Cleveland, Ohio, to work on the first artificial heart programme. On his return to Cape Town he went back to general surgery because he thought heart surgery was too boring.

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First patient, and a decision

It was 1975, somewhere in Southern Angola. I had decided to go for national service because I was not sure what to study. We were pions in a West-East imperialist war for future control of Angola’s riches. We drove into the ambush at dusk and James took a bullet through the ankle. Mark, James and I were lying under the same truck we were in 4 hours earlier. Angolan rain was no joke. We got his boot off; his ankle was getting bigger by the minute, and blue. We had no idea what to do, so gave him 4 Codis tablets and wrapped the ankle so we wouldn’t see the dark blood seeping through, but it looked like toilet paper on a stick. If only we had a proper medic.

The codeine-aspirin combination did not help much for James’ pain, but it made him talk. There was nothing more we could do, but lie next to him to keep him warm. And whisper. The sergeant was on the radio, trying to get an air evac. We knew the chopper pilots would not fly tonight, maybe drunk again. They’re sending an ambulance which will take hours, the road is mined.

At first light the ambulance arrives. James’ leg looks like it will fall off any moment. “Thanks boys” he says, “you’re good to sleep with”. “See you” we said.

We never saw him again but heard that the army doctors saved his leg. “Good outcome” they said. A stiff ankle gets you an honourable discharge for medical reasons. Not a good outcome for a champion 800m athlete. On an Eastern Cape farm you can ride a horse or pick-up truck; there’s no need to run.

The next week I got a message to Dad: “Please confirm that place in medical school, forget engineering”. It took me another 20 years to understand that often we can do nothing for patients except offer them comfort.

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Malawi boy

It is 1985. Every time I looked at her, she seemed more uncomfortable. Her legs were more swollen every day. Pre-eclampsia is not easy in the tropics but maybe it’s not easy anywhere. It was too late to fly her out to South Africa. After the scare with premature labour at 32 weeks she was not flying anywhere anyway. She was now 38 weeks, “so we made it” we thought. Our baby was going to arrive in a small mission hospital in Nkhoma in the Malawian bush. “Time for an induction”, I said, without thinking much of informed consent. Working amongst so much extreme poverty did not give time for reflection.

With the senior midwife we started her on Pitocin on the Saturday. No contractions followed and the cervix was not yet ready. Should we rupture the membranes or wait? We decided to wait 48 hours.

We tried again Monday morning. By now the blood pressure was borderline high and there was 1+ proteinuria. If the induction fails today she would need a C-section. “Who will do the Caesar”, the midwife asks. “I will” I say, “after all, the others ask me if they have a problem case”. This time she responds well to Pitocin. Within an hour she has good contractions and the membranes rupture spontaneously. I feel for a cord but there is none. Four hours later she is fully dilated. She has a lot of pain. I’m too brusque, so focused on being a doctor that I forget to be a husband and expectant father. She has a boy, 3460g, Apgar score 10/10. I suture the episiotomy; she’s embarrassed. “Don’t worry” I say, “nobody will do this better”.

That night we all slept in the same hospital room, our new son with his mother, our two year old daughter and I on a mattress on the floor. We shared a bathroom with an AIDS patient with resistant malaria, the first HIV positive patient diagnosed in our small hospital.

Today he is 30, has taught in Africa with me, and recently we shared working together in Dumfries. A few weeks before he was born I went to an East Africa surgeons’ meeting and heard Dr Imre Loeffler speak, a Hungarian-Austrian surgeon who gave his whole life to surgery in Africa. He said that a first class surgeon could operate in a hammock slung between two palm trees on a beach and have better outcomes than a second class surgeon working in the most modern theatre. A few months later, when in South Africa to show the new boy to the family, I went to see the prof to get a training post. I started one year later.

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Full circle

Before starting surgical practice in 1992 in Upington, the main town of the Kalahari, I went to see GPs in the region, and that took me to dr Jan Meyer in Olifantshoek. He promised to support me. After our meeting I thought to try and find the old Dutch Reformed manse where Dad had been born 70 years before. Dad’s brother had told me that the building commission drew the house plan in the dust with a stick, and according to that the building started. Now there was a new church and manse, and I opened the gate with the “Pastorie” sign, rang the doorbell and asked the young inhabitants if they knew where the old manse was. Nobody knew. I walked dejectedly to my car and, as I started the engine, an old man walked past; he looked part-Tswana, part-San. I rolled down the window and asked him if he maybe knew where the old NG Kerk Pastorie was. “Oh I know exactly where it is”, he said, “it is the house with a wind pump in the back garden”. I asked him to take me there and he got in, moving very slowly because of rheumatism. It was two blocks down, around the corner in a dusty street, a small little square house, still with a wind pump in the back garden, watering all sorts of vegetables and maize patches. I got out to take a picture. The owner came out and asked what I was doing. When I said my father had been born in the house he showed me round. Afterwards I drove my guide to his house in the old African township and I asked him how he knew the house. “When I was a schoolboy, I used to work there on Saturdays for a Reverend Dreyer”, he said; “He paid my school fees. If it was not for him I would not have been able to read and write”. I stopped the car and we both shed a tear for this generous and humble man whose names I wear with pride.

Jan Meyer kept his promise. The first patient I operated on after setting up practice in Upington was an elderly diabetic from Olifantshoek. His father was the lead elder when my grandfather was appointed minister. Granddad did his catechism and I took out his gallbladder; it was beginning to become gangrenous, typical of a diabetic.

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My father and my son have surgical dispositions, much more than I could ever have. When the boy was working in Dumfries, staff kept telling me how he was becoming more like me. That was only half the truth as I was also learning from him. It is when the son not only emulates the father but the father subconsciously starts to emulate the boy that the relationship becomes complete, like my 93 year old father has become dependent on our conversations as much as I once needed his advice. And so we live and learn, love and one day die, in sync and at peace.

@fanusdreyer

http://www.albacccd.com