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

Rights without responsibility… where are we going? by Anne Marshall

“Man must cease attributing his problems to his environment, and learn again to exercise his will – his personal responsibility.”
Albert Einstein

 

‘It’s not my fault.’

‘It’s not fair.’

‘I want that.’

‘Why should they get that when I can’t?’

 

Responsibility – one of those words with which no one much wants to associate these days, but a word that I believe lies at the heart of the change that is essential to sustaining not just the NHS through the 21st century, but life beyond the 21st century.

In his blog Ewan Bell asked how the NHS should prioritise its services – what are the essentials and what should we be doing?

I think we need to turn that thinking round and look at it differently – from the point of view of ensuring that as we empower people we also expect them to be accountable and therefore responsible for the choices they make. . . so here’s a few thoughts and a lot of unanswered questions!

Anne 1The more society gives in terms of allowing individuals to renege on any personal responsibility and the more it protects them from the consequences of their actions and decisions the deeper into this complex and costly moral mire we sink.

So where do we start? Can we make the huge cultural shift required without some horrendous intervention such as war, which inevitably enforces change from selfish desire and want to more simple human need.

How do we teach people to take personal responsibility when they know they simply don’t have to take any because someone else will always pick up the pieces? How do we reduce escalating public expectation? The NHS cannot simply cut back on what it does while society as a whole continues to abandon all sense of personal responsibility; expects more and more to be done for it and litigious greed is ready to pounce on any perceived breach of human rights.

When prisoners win compensation for having the slop out their cells what hope is there of change? Don’t the rest of us have to clean our own toilets?

The fact that benefits are capped at £350 a week but someone on the minimum wage earns only £251.25 before deductions seems to be indicative of where we, as a society, are at. There are few or no consequences for failing to take responsibility. Add to this the fact that publically funded advice agencies actually complete forms for people and lie in order to get them certain benefits which they are neither entitled to nor need and you simply perpetuate perceived dependence, engendering more unnecessary demand and expenditure.

The problem is beautifully illustrated by the story of two students, aged 16 and 19 respectively, sharing a flat. The 16 year old gets her bursary and a job and puts some money aside for the summer months. Her wages fail to come through so she asks for support from the college hardship fund. She is entitled to nothing – because she has put a few pounds aside. The 19 year old blows all her bursary, litters the flat with takeaways and empty drink bottles, builds up a huge debt and gets handed out hundreds of pounds from the hardship fund . . .

Unfortunately the ending is not fair or just, or, more importantly in terms of the NHS, sustainable.

It reminds me of the story of the three little pigs and their houses built with straw, sticks and bricks. Two of the pigs learned their houses were not safe because they had to run for their lives from the big bad wolf and find shelter in the brick house built laboriously by their brother.

We have created a society where there is no big bad wolf – no consequences. We have created a society where people simply expect the state (be it NHS, benefits system, social services or whatever) to sort out all their problems and if they don’t many people either kick up a huge fuss, shout and scream until they get what they want or take on a lawyer.

Anne 2So how do we start to change things and find that balance between a society that takes care of its vulnerable and needy and yet engage differently with those who are outside of the vulnerable and needy group but still think they have the right to whatever they want at whatever cost – as long as it is not to their pocket or life style.

How do we start to embrace the massive moral and cultural shift needed from politicians down and ‘minorities demanding the same rights as majorities’ up? How do we deal with the human rights bill which in its purest form is an excellent and necessary thing but which is so open to interpretation and abuse that it forms a rod for our own backs?

Answers on the back of a postcard please. . . !

“When you blame others, you give up your power to change.”
Unknown

Anne Marshall is a Staff Nurse on the Renal Unit at NHS Dumfries and Galloway

Life after Life by Thalakunte Muniraju

Why should the good things in us stop after death when there is great opportunity for life to continue after life? It is impossible to describe in words the emotional and physical trauma individuals with chronic organ failure experience. I am sure most of you have seen or come across someone whose life has been transformed for the better after organ transplantation.

Kidney failure needing dialysis reduces quality of life and survival significantly. A patient in his/her 30s with kidney failure needing dialysis has a similar chance of having heart disease compared to someone in their 80s without kidney failure. Dialysis replaces some of the functions of kidneys, but not all. Receiving dialysis is almost like having a part-time job; sometimes it can be more than a full-time job if we take into account all the dialysis-associated complications and procedures. To make matters worse, dialysis patients must adhere to lots of dietary and fluid restrictions. A friend of mine once told me that he only started appreciating the taste of water after starting dialysis.

Kidney transplantation is the only treatment which can cure and improve the quality of life and survival in these patients. Yes, kidney transplantation is not without risks and patients have to take lifelong medications to suppress their immune system. But the overall benefits are far superior to being on dialysis. Survival of transplant patients and kidneys has improved significantly – half of the kidneys transplanted from living and deceased donors are still working at 15- and 10-years respectively. One of the immensely satisfying things to see for us as clinicians is to see patients leading a normal life following transplantation.

With the exception of living donation, organ donation is only possible following a sudden, unexpected and most often premature death. We should never lose sight of the families who go through this and should do everything to support them. One of the ways to salvage something positive out of these dreadful events is through organ donation.

Three patients die everyday in the UK waiting for an organ. Over the last 10-years, the number of transplants being performed has increased substantially. Still, a huge gap exists between the numbers of patients active on the list and the number of patients being transplanted (see graphs below). The current UK strategy for organ donation and transplantation, Taking Organ Transplantation to 2020, emphasises the pressing need to reduce family refusal rates. It is disappointing that there has been no improvement in the overall consent (or authorisation) rate in 2014-15. NHS Blood and Transplant continue to devote considerable attention to improving the support that it is giving to families when the possibility of donation is raised.

Muni 1Muni 2On 1st December 2015, Wales became the first UK country to introduce a “soft opt-out” system for organ donation. It will be interesting to see what impact this will have on the number of transplants in Wales in specific and subsequently, the UK as a whole. Earlier this year Scottish government said it would consider bringing forward new legislation on an “opt-out” system for organ donation.

Hopefully one day in the near future we will see an “opt-out” system in whole of UK, for the benefit of our patients with organ failure.

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Registering online takes less than two minutes. After registration make sure that your family and friends know about your wishes. This is the only way to continuously increase the transplant activity, and give someone gift of life. Please consider giving life after life…

https://www.organdonation.nhs.uk/register-to-donate/

http://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2014_15.pdfb

http://www.bts.org.uk

Dr Thalakunte Muniraju is a Consultant Nephrologist at NHS Dumfries and Galloway

 

 

Fire in your belly by Euan Macleod

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What is the fire in your belly?

Euan 2When it comes to what you do? Do you feel passion for it and are you excited about the possibilities that could come your way, or is it a bit like the guys with the Gaviscon have just hosed you down and your fire is quelled?

 

 

Fire in your belly-you know when you’ve got it

You feel it

Euan 3Sometimes it is hard to find time to listen to our feelings in the midst of busy work schedules, the passion that you first felt when you entered a career in the NHS may have become blunted by the daily trudge-is it always going to be like that?

I recently mentioned in a blog the creation of the NHS and the welfare state.

Beveridge had a passion for that, but where did that passion come from?

Beveridge’ report might have been destined to be another dry and dusty Government document. What made it a huge public best seller was its breathtaking vision and passionate language. The fiery rhetoric largely came from Scotland after weekends spent with Jessy Mair in the spring and summer of 1942.

Jessy was Beveridge’s close confidante and companion for many years. His biographer, Jose Harris, highlights her influence on him during his visits north of the border:

“Much of his report was drafted after weekends with her in Edinburgh and it was she who urged him to imbue his proposals with a ‘Cromwellian spirit’ and messianic tone. ‘How I hope you are going to preach against all gangsters,’ she wrote. ‘who for their mutual gain support one another in upholding all the rest. For that is really what is happening still in England’. . . .”

Beveridge didn’t miss; the report sold 100,000 copies within a month. Special editions were printed for the forces.

The gangsters referred to by Jessy Mair were the deliverers of health care who profited from the sickness, squalor and disease prevalent at that time. Beveridge clarion call to a sense of community welfare based on need and not ability to pay heralded the start of the NHS.

No surprise that today many of us remain passionate about the values and aspirations of the health service, a service that many of us have experienced as employees, patients and carers of loved ones. There is still some fiery rhetoric and a will to retain and improve on the values and service which the NHS provides.

But it won’t be easy in this time of austerity.

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It might need

Guts-More fight

Grit-More passion

Gumption-Being courageous

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It means that you find a way to get better

It means that you’re putting in every ounce of extra effort you have

It means that you get pushed down but don’t stay there

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Easy to say

Perhaps harder to achieve

But unstoppable when it starts

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So what’s your passion and where is it taking you? Share the fire in your belly, it could start a bonfire

Euan McLeod is a Senior Project Officer for the National Bed Planning Toolkit

 

 

 

 

‘Walk a mile in someone else’s shoes…’ by @Rosgray

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I remember reading a paper a few years ago now that said (something along the lines of) when thinking about the strategic direction of your organisation, you can focus on customer needs and experience, or you can focus on staff needs and experience. It doesn’t matter which, as long as you focus on one, as the quality of the service you deliver will improve. You just need to focus!

As a staff member I get the point, and as someone who works for the public sector it also feels right to put our focus on the needs of our customers.

So there is a lot of conversation in health and social care just now about the concept of asking patients and others “What matters to you?”. It is generally agreed that it can help us understand their needs and maybe understanding of the position they find themselves in under our care. In some cases it has fundamentally redefined the way the service is delivered and often in ways that health care teams might never have dreamed possible.

Ros G 2The newest Scottish hospital has integrated a systematic approach to delivering ‘what matters to me’ for every patient…

 

But all this got me to thinking – if I was a patient today, what would I put on that board?

I have a small family, a daughter’s wedding imminent, I am an only child so no major significant others to accommodate, so I guess they would need to be on there.

But what else would I say?

Reflecting on a fairly recent hospital admission, I had great confidence in the clinicians (a given…) I wasn’t so confident about hand hygiene; I wasn’t eating much so I was really interested in getting hot soup…

Ros G 3So would my WMTM board say – that your hands are clean (and show me how); I like my soup hot; and ask me about my mother of the bride outfit?

Probably…

But the important thing is that it would give us the opportunity to explore what was underneath those words and begin to consider the differences between asking ‘What’s the matter’ and ‘What matters’ and to understand the patients concerns and goals for clinical outcomes and managing life limiting, long term or indeed any conditions.

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Some say you absolutely cannot walk in someone else’s shoes. Our history makes us who we are; our perspectives, our successes and failures, our experiences. We cannot put ourselves in someone else’s position in exactly the same way, at best, we can be open, to listen and truly hear, to get more information and be better placed to understand and be prepared to do things in a different way.

And that can be tough.

It can be tough on us as professionals trying hard to deliver a service in increasingly challenging times.

But I suggest it might also be rewarding, bring back the reason we went into this kind of work in the first place, and make that work more enjoyable, knowing that we are engineering a different approach to care delivery that is focused on what matters to our patients. Delivering the care to them as we would the ones we love.

So let me leave you with time to reflect…

What would be on your ‘What Matters to Me’ board?

How will you develop ways to ask your patients about what matters to them?

And how will you use that information to deliver the service differently for them and others in the future?

Because that could be you and yours…

While I accept we cant walk exactly in someone else’s shoes, some of our healthcare colleagues in the USA have attempted to open our eyes a little with this short video.

‘Could a greater miracle take place than to look through each others eyes for an instant?’ Henry David Thoreau

https://www.youtube.com/watch?v=cDDWvj_q-o8

Ros Gray is Head of the Early Years Collaborative for the Scottish Government

Kathleen’s Journey

How many of you have lost a loved one to cancer? How many of you have heard the term “he or she died peacefully”? Anyone who has witnessed a loved one dying in this way will appreciate that there is often nothing peaceful about it. It is heartbreaking, you are in fearful limbo, undergoing constant challenges and the result is painful and exhausting both physically and mentally. This may sound a little dramatic but it is an honest assessment and it was honesty which I felt was lacking in the story I wish to tell you.

At the beginning of 2014 Kathleen, my Mum, had a follow up Colonoscopy having previously had polyps. However on the day the procedure was performed there were complications and the test was abandoned. She was informed she would be recalled but sadly had not yet received this appointment at the beginning of 2015, when she died.

She became unwell during the summer of 2014; fatigue, loss of appetite and change in bowel habit. As her symptoms worsened she isolated herself socially. Her GP prescribed laxatives but they just made things worse and caused abdominal pain. I would say at this point she had no quality of life. She visited her GP and asked for more investigations but was informed that tests such as CT scans were expensive and she did not require one. This shocked us.

In November her abdomen became distended and the pain became worse. We were left with no option other than to take her to the Emergency Department. To my horror Mum was sent home with more laxatives but was so poorly had to return the next day. Once again they wished to discharge her but my dad stuck to his guns and insisted on admission. She had a number of tests and on the following Tuesday a CT of her abdomen. This revealed bowel and ovarian cancer. 

When Dad was asked by the Consultant to be present when he gave Mum the results he knew it was going to be bad. The Consultant informed them that the cancer had spread and that Mum only had weeks to live. There was no treatment to offer. There is no skirting around news like that. It was devastating but we were grateful that it was delivered with humanity, compassion and honesty. You don’t forget these things. As a family were reeling. The grandchildren were heartbroken and we all struggled to come to terms with the news. And then…..

A few days later another doctor came and told us the CT results were ‘inconclusive’. This news was delivered with a flippancy and obvious lack of understanding to how we all felt. We were then told that it would be over a week until we knew what the plan was as we needed to wait for a multidisciplinary meeting. This was almost too much but we clung to the hope now presented to us. Maybe….

Then we were told that there was no curative treatment but there was an option of palliative chemotherapy which MAY shrink the tumours. They offered 6 months of chemo which sounded hopeful and Mum went up to Edinburgh. However after the first course she suffered a perforated bowel, apparently as a result of the chemo, and was admitted to the palliative care unit. She was now asked what she wanted and discussion turned to the funeral!

Why was my Mothers final 6 months such a roller coaster? Why did it take so long to diagnose her? The end result would most likely have been the same but did she have to go through so much pain and confusion? I understand that an administrative error led to Mum not getting her follow up colonoscopy. This is inexcusable but when she became truly ill no-one seemed to listen to her. Listen to her symptoms, listen to her story. Had an individual healthcare professional actually listened to Mum or Dad and taken them seriously then I have no doubt she would have at least had her scan and diagnosis earlier.

And then all the confusion about “was it cancer or was it not?” It clearly was and the first Consultant we saw was clear about this and, not only did he honestly tell us the news and prognosis, he was right: she only had a few weeks left. A few weeks that could have been much kinder had she not been given false hope and a worthless (and uncomfortable) trip to Edinburgh. It was only when she got to the palliative care unit that they asked….What matters to You?

That is all it required….someone to listen and honesty.

Mum died in the palliative care unit well cared for and in dignity. The staff were honest and kind. They listened to her needs and provided them. We are very grateful to them and their professionalism.

This week’s blogger wishes to remain anonymous

Team work – Ward 12 style by @jacalinanicnac

I have been nursing for 33 years this November and over those years I have experienced a variety of good and not so good team working. Those experiences have influenced me greatly to form the nurse and team leader I am today.

My job as Senior Charge Nurse in Ward 12 is to provide a high standard of effective care in an environment that patients feel safe in and by a team that feel confident and supported to do so , and everything else that falls within the patient / relative experience. Working in a team can be challenging but also fulfilling when the job is done well. We couldn’t do what we do every day without good team work .

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WHAT IS A TEAM?

A group of people that share a common purpose, are committed and empowered to set goals and problem solve. Without these traits they are not a team but a group of people who work together, a work group.

Jackie 2A patient sent us this thank-you card ,

“Together Everyone Achieves More”

Together = we have a common purpose = giving excellent care.

Everyone = all who work in Ward 12= everyone has a voice.

Achieves = how we deliver our care = evidence based, safe and effective.

My role as team leader is to make clear the team goals, identify the issues that stop the team from achieving their goals and solve those issues with the help of the team .We would do this by doing tests of change , getting feedback and auditing improvement . My job is to create an environment where team members are supported and valued in the work place .By keeping the team motivated, developing and maintaining skills, being aware of individual strengths and weaknesses and attitudes and behaviours I can enhance the staff experience. I was encouraged and guided by work done by Julie Booth, Senior Charge Nurse in Ward 3. Julie and her team developed Values and Standards for the ward. All our staff had input in developing the ward standards and all staff agree to work by them. The basis for the Values and Standards is respect, being non judgemental, and being respectfully open and honest in giving and receiving feedback.

As well as the patient wellbeing, the wellbeing of my staff has equal standing. I believe you can’t enhance or improve the patients experience unless you value and enhance your staff experience. I have encouraged staff to attend the National Person Centred Health and Care Programme, and our local Patient experience events. The staff come back to the ward enthused with ideas for change, they share them with colleagues and then as a team we plan how best to introduce those changes to the benefit of patients and staff.

One such idea was after a local Patient Experience event. Team members returned to the ward and wanted to introduce reflection for staff. The team felt that after a busy shift there was no opportunity for them to say how that shift was for them. Staff felt they took their thoughts home and returned on their next shift with heavy minds and frustrations from the previous shift.

We have a definition of reflection, an aim and a process for reflection. The purpose of the reflection session was to be able to speak freely about their experience of that shift , any challenges and to discuss what could have worked better, or to say what was good about that shift and how that could be embedded. It is time limited to 10 minutes at a convenient time, it involves all nurses on the shift, there is a lead person for the session (not necessarily the Senior Charge Nurse, or person in charge), and ground rules were established = confidential- no notes taken – what was said in the room stayed in the room, discussions are relaxed and non confrontational, open and honest. Any “bigger” issues arising would be discussed with the staff member and myself out with the reflection session. The sessions were greeted with apprehension by some staff who found it difficult to speak about their experiences, but after a few sessions everyone soon got into the swing of it. These sessions were soon generating ideas for improvement and themes of frustrations in the work place. We added 2 boxes , one where staff could write down their good ideas =Golden Nuggets box, and one where they could write what was annoying on their shift = The Bug box.( replacing what you had used and tidying up were the top 2 ). We then discuss what is in the boxes each week and plan how to improve or change our practice. We have a questionnaire for staff for feedback and we use the safety cross check chart per month to record our consistency. We saw very quickly that staff felt they had the chance to reflect on the challenges and the successes of their shift and by giving everyone the chance to talk about it freely the staff felt they no longer left work feeling burdened by “work stuff”. This has improved our communication within the team and improved staff morale .It takes commitment by all staff to maintain these sessions, when we are extremely busy some sessions do not happen and the staff comment that they miss them. It is my job to raise the focus again and encourage the staff to keep it going.

Jackie 3

Dale Stewart and Wendy Langan who facilitated the reflection development.

Another idea introduced by the Health Care Support Workers in the ward was to have a welcome and information leaflet for all staff coming to help in the ward. It starts with thank you for coming to help in the ward today, you will be working with….. , the ward routine is…. , your break is… . We have feedback sheets which we review monthly and encourage suggestions to improve staff’s short term experience whilst in ward12. We have had a lot of positive feedback from staff helping in the ward and they look forward to coming again.

By encouraging staff to develop their ideas and improve the team performance they take ownership of change and enthuse others to do the same. This makes my job easier it enhances the patient care and journey which we measure with our patient questionnaires; What did we do well? What could we have done better?

Being part of a good team gives you a sense of pride in achievement and celebrating success, and camaraderie in supporting the team. In Ward 12 a wicked sense of humour and a liking for sarcasm will also enhance your experience!

 Jackie 4

Celebrating success , Susan ,Drew and Mary.

I would like to dedicate this blog to Charge Nurse Heather Renwick who retires this week after an outstanding 37 year nursing career, one of my excellent experiences in my nursing career.

Jackie Nicholson is the Senior Charge Nurse on Ward 12 at Dumfries and Galloway Royal Infirmary