Death by a Thousand Paper Cuts by Richard Akintayo

Black History Month

To mark Black History Month 2023, we present an article written by the Chair of the Ethnic Minority Staff Network and Consultant Rheumatologist, Dr Richard Akintayo, on the subject of microaggression.

In the first few months after I moved from Nigeria to the UK, and for the first time in my career as a doctor, I lived close enough to walk to work, and I was quick to fall in love with my daily commute. When I shared the positive impact of this routine physical exercise with a work colleague, they seemed surprised and asked, ‘So in Nigeria, did you always drive to work?’  

‘Yes, and I’m really enjoying the walks now,’ I answered.  

‘That’s interesting, considering all the news we always hear of people walking several kilometres to fetch water in Africa,’ was this colleague’s reply.  

Reading about this experience may make a neutral person feel upset that I got treated that way. However, the truth is that various degrees of statements like this – and often subtler ones – slip their way into everyday workplace interactions, and many people don’t even see them as grossly inappropriate. Even those at the receiving end of treatments like this often come to accept them as normal. Sometimes, the person treating you that way may even have good intentions. This is microaggression. If someone is holding a dagger menacingly whilst talking to you with disgust on their face, it’s not hard to see the danger. But it’s a different story if all they wield is paper and a smile (or sometimes disgust) yet are cutting you now and again with the paper – whether they mean to or not.  

A subtle act of exclusion  

The term microaggression is used to describe everyday, thinly veiled hostility towards a group of people, usually people belonging to a marginalised group. Microaggression takes the form of verbal, behavioural or environmental slights – basically subtle acts of exclusion. Unfortunately, many incidents of microaggression are driven by unconscious negative reactions. Even when microaggressions are unintentional, however, their impact on individuals and organisations can be significant.  

Microaggressions are especially common in the workplace, and they deliver unfriendly meta-communications in which their targets are made to feel excluded or demeaned. They can be verbal acts like saying, ‘The best person should get the job regardless of their race,’ implying that institutional racism does not exist and people don’t miss opportunities because of their race. Saying to a person of colour, ‘Everyone can succeed in this society, if they work hard enough’ suggests that laziness is the only reason some people don’t reach the peak of their potential; and saying, ‘As a woman, I know what you go through as a racial minority’ implies that the racism you suffer is not worse than my gender oppression; therefore, I’m just like you and cannot be racist.” Attempting to dismiss the injustice which black people face by saying, ‘All lives matter’ in response to the Black Lives Matter movement is like going to a campaign against prostate cancer to agitate that all cancers should be talked about.  

Behavioural microaggressions are things like avoiding getting in a lift because a person of colour is there. Or hurriedly clutching your bag if you were already in the lift when the person of colour enters. Environmental microaggressions include having a leadership rank that doesn’t include persons of colour, despite having a significant number of competent ethnic minorities among the staff. Microaggressions are a manifestation of implicit bias and may be seemingly invisible despite their rifeness in a workplace that is not challenging them.  

Put-downs that put us all down  

Although members of the Western workplace now report being more accepting of people of colour than, say, before 1807 when the slave trade was abolished in the British empire, there is still a significant gap between what people claim to believe and how they act towards ethnic minorities. A PhD thesis published by the University of Georgia shows that not only are the recipients of microaggressions hurt, teams and organisations equally suffer from the impact of these behaviours. (1) Employees at the receiving end of microaggression are more likely to report experiencing negative emotions than the control group but are not necessarily more likely to respond aggressively in order to avoid conforming to unhelpful stereotypes such as the ‘angry Black person’. Team efficacy has also been shown to be diminished in an environment harbouring microaggressive behaviours, and there is an overall decline in self-esteem and increased burnout.   

Similarly, microaggressions damage trust in coworkers, management and the organisation. Immigrant professionals, many of whom are ethnic minorities, make up a significant proportion of the NHS workforce, and the system relies on the proper delivery of service by all the professionals within it to deliver its goals. Yet, evidence around the pervasiveness of racism in the NHS continues to emerge. For example, in a recent British Medical Association national survey, 76 per cent of respondents said they had experienced at least one incident of racist behaviour in the preceding couple of years and 17 per cent stated that they experienced it regularly. (2)  

Whereas the impact of a single episode of microaggression might not stand out menacingly, unending barrages of various forms of this pattern of hostility can very well damage the confidence and career prospects of the victim and wreak huge harms on the service itself. Holding a dagger to the figurative neck of a person’s career is obvious in its intent to kill, but subjecting that same career to endless injuries from microaggression is like delivering death by a thousand paper cuts. 

How on earth did we get here?  

Evolutionary theorists have suggested that some of our discriminatory behaviours towards other races may be linked to documented historical reactions to outgroups as seemingly constituting inherent threats. A 2015 study published in the Journal of International and Global Studies posits that the mainspring of outgroup prejudice is a triggered sense of distrust and caution. Early humans relied on heightened levels of vigilance and suspicion to protect themselves and their offspring from intruding dangers, including those posed by other humans. In essence, prejudice is a product of a self-preservation outlook rather than a specific attribute of any given outgroup.(3) Evolutionary psychologists Carlos Navarrete and colleagues argue that racism itself is not so much based on the ingroup innate preconception of risk posed by the outgroup but is strongly determined by established cultural and social norms.(4)   

A powerful pointer against the normalisation of racial prejudice driven by intergroup biases is reducing this bias through common motivation with people of other races—for instance, when a mixed-race group must work together to achieve a goal that all members believe in and are keen about. Suddenly, the bias either goes away or is significantly reduced due to the common group identity.(5) In other words, the acceptance of ‘the other’ as ‘same’ can eliminate conscious and unconscious racial biases and likely race-based microaggressions, even the ubiquitous ones that have been seen as nearly innocuous. This suggests that racially discriminatory behaviours may have been learned and can very well be unlearned.  

The danger of the inactive bystander  

Racism and microaggression continue, at least in part, because the perpetrators have the instinctive conviction that other people of their race will back them up, protect them from facing the consequences of their action or even punish the victim further if they raise an issue. Many people of colour have had people they’ve known and worked with harmoniously for a long time suddenly refuse to help them when they receive a racially motivated attack, whether subtle or overt. Sometimes, the victim even ends up thrown under the bus and the weight of evidence is twisted around to paint them as the hostile one.   

Everybody must think about themself first. Many people cannot afford to risk being thrown out by their own tribe for accepting the moral responsibility of taking a nonconforming stand to help someone who’s been mistreated. Unfortunately, this type of self-preservation effort simply sustains the culture of marginalising the ethnic minority and undermining the principle of social justice that many organisations like to associate with – all the more reason why an organisation’s prevailing culture is ultimately the responsibility of its leadership.   

If we choose to adopt tactical neutrality when complaints of microaggressions are made, or we find a way to silence the complainant, we’re providing negative reinforcement for the action of the aggressor, who in turn sees no need to change. In fact, it’s like injecting dopamine, the biological currency for reward and pleasure, into the brain of the perpetrator to see the victim ignored, gaslighted or blamed for making an issue of the incident. As the ultimate management principle says, you get what you reward. We may well have created an environment for victims of microaggressions to live in fear of the toxic culture they work in. A true fear of career death by a thousand paper cuts and maybe a dagger stab at some point.  

In our highly politically charged world, words like injustice, discrimination and microaggression may trigger people in different ways. They may lead us to take an emotion-driven stand on any discussion that follows and spend our logical reasoning defending a position we chose based on emotion. It may even make us resolve to actively oppose any argument that suggests that neutrality is complicity, because we take offence at reasoning that we interpret as trying to guilt us into taking sides. However, it is not merely being pressured to take sides if we indeed have the power to make a positive difference on an issue that we fundamentally agree, and probably openly profess, is wrong. Choosing to not lift a finger in such a situation is simply empowering the aggressor, and it does send a message.  

Who does see no evil, hear no evil help?  

The workplace often encourages people to conform to certain types of behaviour that serve to promote what the organisation sees as professionalism – but this can also encourage not making a mountain out of the mole’s hill of micro-injustice. In other words, having to keep your human face (and whatever burden of morality you carry around) a little bit masked. The culture of being afraid of getting into trouble for rocking the boat of a system that looks away from microaggression is likely ensuring a perpetual succession of patterns of behaviour that can damage employee morale. Some ethnic minorities may even learn a dysfunctional coping strategy of kicking down on other ethnic minorities and kissing up to the establishment to signal that they don’t want to be considered part of ‘the other’.   

If what it would take for a person of colour to not be held back by the well-documented differential attainment trend between white employees and employees of colour is to enthusiastically play the office politics that may harm the wellbeing and career prospects of other ethnic minorities, even they might have no problem keeping mum at the sight of microaggression. After all, that may be what it takes to properly blend in. This means, of course, that if everyone goes around pretending not to notice the mistreatment of their colleagues or is too afraid to help the victim in any way, the perpetrator benefits and has no real reason to change. Sadly, if you help an aggressor cover up racially motivated hostility today, you can also expect them to do the same for you when you also kick down an ethnic minority. That is how to use the race card without using the race card. 

You cannot believe everything you think  

That everyone has good intentions is one of the key presuppositions of neurolinguistic programming, the study of the structure of our subjective experience. This implies that altruism, benevolence and even verbal slights and violence can all be thought of as behaviours geared towards pursuing a primary outcome which the person believes is positive. From the point of view of promoting tolerance and increasing the chance that we might consider the point of view of the other person, this is all reasonable. However, more than a hundred years since the abolition of slavery, sometimes we all need to examine the unconscious beliefs and values that drive our outgroup prejudice and inform our biases. We are living in the best time in the history of humankind – socially, economically, technologically. After millions of years of humans and about 300,000 years of our species, some of the lessons from our ancestral environments may no longer serve us very well. This is why we need to heed the warning of Carl Jung, the Swiss psychoanalyst who advised that if you don’t make the unconscious conscious, it will direct your life and you’ll call it fate. There are ample reasons to be optimistic for the future, but optimism can be active or passive. It is passive when we believe that things will get better, but it is even more potent in the active form when we believe that we can make things better.   

How does this make you feel?  

We all have a role to play in creating a work environment where each of us can flourish. It takes courage to go against our usual pattern of behaviour the next time we witness microaggression that is not directed at us, but seeing the situation for what it is and reminding ourselves that we all have a responsibility to stand for a positive change is a good place to start. It may even take an unexpected amount of energy to restrain yourself the next time you want to say or do something demeaning to a colleague, if this has been your habit. Our emotions, negative and positive, are always trustworthy signals to us about ourselves and our values. Reading this article, for instance, may have triggered some form of feeling within you. Anger, disgust, pleasure, guilt, fear, annoyance, compassion, surprise, shame or maybe even horror; whatever it is, it’s worth reflecting on why you might be feeling what you’re feeling. I bet that at the deep end of that feeling is some call to action.  

1. Alinor M. Reacting to Racism: Examining the Emotional and Behavioral Outcomes Related to Racial Discrimination: University of Georgia; 2021. 
2. https://www.bma.org.uk/news-and-opinion/racism-an-issue-in-nhs-finds-survey  
3. Kaya, Serdar Ph.D. (2015) “Outgroup Prejudice from an Evolutionary Perspective: Survey Evidence from Europe,” Journal of International and Global Studies: Vol. 7: No. 1, Article 2. Available at: https://digitalcommons.lindenwood.edu/jigs/vol7/iss1/2  
4. Navarrete, C.D., Fessler, D.M., Fleischman, D.S. and Geyer, J., 2009. Race bias tracks conception risk across the menstrual cycle. Psychological Science, 20(6), pp.661-665.  
5. Kurzban, R.; Tooby, J.; Cosmides, L. (2001). “Can race be erased? Coalitional computation and social categorization”. Proceedings of the National Academy of Sciences. 98 (26): 15387-15392.  

Who/what is a SAS Doctor? by Shona Donaldson

It can be a confusing title. We aren’t in the Special Forces but we are sometimes as skilled in negotiation, hostage rescue, and covert reconnaissance!

SAS stands for Specialist, Associate Specialist and Specialty Doctors, we were initially called Staff Grade doctors, and over the years this has changed to describe the level of independent working we do. We are around 10% of the medical workforce in Scotland. We haven’t been through the challenging training of the consultants in the UK but have often done so overseas or worked in a medical field for some time and achieved similar qualifications.  I have been working as a Staff Grade, then Associate Specialist in care of the elderly for over twenty years and have seen the health service and the hierarchy change significantly in that time.

My job was initially a “service provision”, to help steer us through the challenging time of junior doctor hours negotiation and to provide continuity to departments and patients. Gradually we have been given more opportunities to develop skills, work independently and develop extended roles.

We have the SAS Charter to support and develop the role of the SAS doctor as a valued and vital part of the medical workforce in Scotland. We also had a new contract for Specialty Doctors at the end of 2022 with a new post of Specialist Doctor which can be advertised, if appropriate, for those with ten years postgraduate experience, 6 of those in their chosen field. This could open up exciting opportunities for the future, allowing a degree of autonomy only previously available to consultants. The Associate Specialist grade is closed, allowing no new positions, there are a few of us left, with senior positions in various departments.

I am privileged now to work as the Education Adviser for SAS doctors in Dumfries and Galloway, with support from a fantastic team at NES (NHS Education for Scotland). I aim to help with educational opportunities for our group of around 60 doctors who don’t fit into the training grades’ teaching group but are keen to keep learning. Some of our group are aiming to become consultants in the UK through CESR (Certificate of Eligibility for the Specialist Register) and others are developing special skills for clinical application using the Development fund from NES. We have local education meetings with lots of opportunities nationally.

We are everywhere, you may not have noticed us. We have SAS in lots of roles, such as chair of Medical staff committee, Specialty Team Leads, education leads and Associate Medical Director, to name but a few. NES has always encouraged us to use our skills to the maximum and develop leadership qualities alongside our clinical practice. Dumfries and Galloway has many successful SAS doctors, who have been and still are an inspiration to me.

This week (9-13^th October) is SAS doctors’ week, raising awareness of our grade and understanding who we are. I hope this helps clarify who we are and what we do.

Dr Shona Donaldson is an Associate Specialist in Care of the Elderly and SAS Doctors Education Advisor for NHS Dumfries and Galloway

Early Intervention for Psychosis by Katie Whyte

Perhaps too many years ago to admit; I had the fortune to become involved in the life of a young man who was diagnosed with schizophrenia.   I met him when he was first admitted, in his late teens; distressed, paranoid and suspicious and not exactly welcoming of inpatient treatment.  I tried to offer a sense of hope for recovery and provided him with the space to talk about his reservations about medication and his frustration with what he felt was restrictive and coercive mental health care.  Our relationship continued over the years when he experienced relapse and returned to the ward environment, usually detained under the mental health act, having stopped his anti-psychotic due to his perception that he was not unwell and his frustration about side effects of his medication.  Latterly, I felt hopeful when he appeared to gain some insight into his difficulties and was adhering to his medication.  But as a consequence, he was wrestling with the reality that whilst his siblings and peers were getting married, having children and settling into careers and new adventures, the reality for him was living on his own with an impoverished social network, unemployment, considerable weight gain with its resultant impact on his physical health, and a sense of hopelessness for the future.

It was with a heavy heart that a few months later, I found myself meeting his parents, for the first time, at his funeral.  I will never forget the compassion and gratitude that his parents expressed to me, and to the service, for supporting their son over the years.  As a parent myself, I often wonder why they were not angry and why they didn’t ask what we could have done better to prevent this tragic and untimely loss.  Because, the reality is, we, and I, could have done better.

In the first year of experiencing psychosis, a person is 12 times more at risk of taking their own life than the general population.  Suicide is the leading cause of premature death in individuals diagnosed with schizophrenia.  But a third of people who present with psychosis recover and never have another episode.  The trick, like most things in healthcare, is getting help early.  The challenge is doing this with people who either don’t think there’s anything wrong, don’t ask for help, or their living circumstances and lifestyles don’t exactly match our service model.

For the last year and half, I have had the pleasure of working with colleagues locally with support from third sector agencies, people with lived experience and Health Improvement Scotland to pilot an Early Intervention Psychosis service in our rural health board.  A first for Scotland, the naysayers challenge the need for this highly intensive, assertive approach to a relatively small group of service users when resources are increasingly rationalised and services overrun with demand.  Psychosis usually occurs for the first time in late adolescence or early 20s and if life goes off track for you then, the impact is arguably much more significant than if you have already met some of life’s important developmental milestones.  If we can get people treatment early and intensively, we can de-stigmatise psychosis and give hope for recovery and offer co-ordinated treatment including working alongside family and carers, vocational support and evidence based psychological therapies.  We can prevent hospital admissions, get people back to work or studies, improve relationships with their loved ones, reduce carer stress, and crucially, keep people alive.       

If you would like more information about Early Intervention Psychosis and our team, please get in touch and we’d be delighted to talk more about what we are doing, and what we hope to achieve in the future.

Katie Whyte is a Consultant Clinical Psychologist for NHS Dumfries and Galloway

Katie with Jamie Henderson (EIP Key Worker) & their Quality Improvement Trophy

The immeasurable importance of clinical trials -A guinea pig’s perspective and personal journey by Jamie Logan

Late October 2020, I woke with a feeling that a butterfly was using a battering ram to burst out of my chest. Shortness of breath, light headedness and chest tightness closely followed.
My first thought – “you’ve got me Covid, I’m ready for you – give me your best shot!”
Testing for “Corona” was routine back then, and to my great surprise, only one line was revealed.
What was happening to me?
I explained the symptoms to my GP and was immediately started on beta-blockers to slow my heart and anti-hypertensives to lower my blood pressure, then was referred to cardiology.
Fast forward 3 months and extensive tests (echos, MRI, Exercise testing), I was diagnosed with a heart condition- obstructive hypertrophic cardiomyopathy. Shock – this is hereditary. I was born with this – Mum had bowel cancer and is still going strong. Dad – not so lucky – Parkinson’s with Alzheimer’s and passed away 8 years ago. Neither were symptomatic, and I have since learned that my older sibling has recently been diagnosed with the same.
I was asked to look on British Heart Foundation website to familiarise myself with my condition, and in bold letters it stated : Possible Sudden Death ……….. this was getting scary!
I had always been active, a couple of marathons in the bag – so now I know why it took me 6 and a half hours to complete!
Absorbing this over a few further months, I was approached by a geneticist in Glasgow who took an extensive family history. As I had concerns I needed to talk about, she transferred my call to a Consultant Cardiologist, who invited me to a consultation in Glasgow.

This resulted in an informed invitation to trial a new unlicensed medication which would potentially treat my condition rather than the meds I was taking. These existing meds only helped control my symptoms, which admittedly had some undesirable side effects. I was screened in September 2022, passed the criteria required and was double blinded in the trial, unaware if I was on a placebo or the real deal.
Now, off the initial trial and awaiting results to determine if I was positive or negative for the medication, I have been given a further opportunity to participate in an extension for further research.  I actually know this time that I am on the Real McCoy now, and will remain on this until the time when enough statistics, hopefully favourable, will allow licensing. To be given the chance to participate is something so significant, to eventually help so many, leaves me feeling very humble.
I’ve been informed that there are less than 300 participants “world-wide”. The research team have been so supportive, as the emotion of coping with this has been overwhelming at times.

Don’t get me wrong, it’s not been all smooth running and there are factors that need to be considered – Long full days including travelling to research centre in Glasgow –( now made easier as I am taxied from home). Commitment for the long term study, and factoring in time off work to attend clinics. There was anxiety and reservations, from both myself and family, regarding untested medications – I was, in essence, a vulnerable candidate seeking a cure.

However, had I not been given this opportunity, I may well have resigned myself to the prospect of invasive surgery.

This has given me new hope.
Research is the essence to drive and develop new techniques, treatments as well as medications. Onwards and upwards, we learn as we go – development is essential for survival in a volatile environment, passing on the healthy outcomes ultimately to our service users.

Jamie Logan, Highly Specialist MSK Physiotherapist

Mountainhall Treatment Centre

Too Much Coming In The Door That Could Be Prevented by Lesley Brown

The Scottish Allied Health Professions Public Health Strategic Framework Implementation Plan 2022 to 2027 sets out the ambitions for AHPs, their partners including NHS Boards to progress, support and enable AHP’s to improve public health in the population, to reduce health inequalities and encourage self-management and self care through prevention and early intervention.

In April 2023 I was successful in my application to receive funding from NES AHP Careers Fellowship programme to focus on Health Inequalities.  I am one of 19 AHP’s and AHP Healthcare Support Workers to receive funding of up to 2 days a week to focus on personal development and delivering a project within the workplace.  Funding allows dedicated time to focus and understand our caseload of those with a diagnosis of Diabetes,  Peripheral Arterial Disease (PAD),  by gathering important data about the social determinants, economic and environmental factors which impact on individual’s health and wellbeing.  The other aspect of the project focuses on developing our Team, delivering a One Year Action Plan to lead and support transformative change for our service and contribution to tackling health inequalities for individuals and communities in Dumfries and Galloway. 

One Year Action Plan Themes

Health Inequalities are the unfair and avoidable differences in people’s health across social groups and between different population groups.  To tackle health inequalities requires action that addresses three fundamental drivers of social inequality, power, income and wealth.  These drivers affect the distribution of wider environmental influences on health, such as availability of good quality housing, work, education and learning opportunities, as well as access to services.

When we talk about health inequalities, it is useful to be clear on which measures are unequally distributed and between which people. The only way to really evaluate if your service is providing inclusive and equitable care is to understand the community you’re working with, both on a local level, and in terms of the clinical population.  How do you know if you are seeing who you should expect to be seeing within your service?

To focus and understand the more complex part of the Podiatry caseload, for individuals with a diagnosis of diabetes and PAD is vitally important for service planning and delivery of care.  Diabetes costs NHS Scotland around £1 billion pound each year, of which approximately 80% (£800 million) is spent treating potential avoidable complications. Furthermore, around 12 per cent of the total inpatient budget in Scotland goes on treating diabetes and its complications.  It is important that individuals engage with diabetes services, glucose monitoring, have access to person centred education, support resources, online learning, with pathways to enable and empower self-management, to help reduce these complications.

Peripheral arterial disease (PAD) is a common problem which affects 9% of the population. PAD is closely associated with age and with the prevalence of diabetes, brings a high risk of death and disability, particularly leg amputation, and is a strong marker of more extensive arterial disease. Around 1–2 % of people with PAD will undergo amputation within 5 years, making PAD one of the biggest causes of lower-limb amputation in the UK. PAD can be largely treated through medication and lifestyle changes to help reduced the risk of developing coronary heart disease, stroke and loss of limb.

Therefore it is important that we ensure we are working with people to prevent the onset or progression of disease and preventing inappropriate use of health services should be seen as a way to manage growing demand in a more sustainable way.

Lesley Brown is Team Lead East/Professional Advisor Podiatry Services for Dumfries and Galloway Health and Social Care Partnership

Triggered by Anonymous

The recent Christmas party video, filmed during lockdown in December 2020, which emanated from 10 Downing Street, filled me with rage. I watched the people involved, who weren’t socially distanced or wearing masks, drinking, dancing, singing and laughing in the workplace far removed from the measures that others were held to. I couldn’t believe the blatant disregard for the rules and even the mocking of them as if they were insignificant.  It seems that the horrors of covid had affected me and continue to affect me more than I ever realised they had.

Working in CCU at that time my own reality, and that of my colleagues, was very different. I remember the very odd calm before the storm, just waiting for the first covid+ patient to be admitted. I remember the unit being prepared and stocked with PPE and half of the unit being sealed off to accommodate covid+ patients. I remember my first shift in the, ‘covid end’, removing all the personal items from my pockets and sealing them in a bag, putting on all the necessary PPE over my uniform, sterile surgical gown, gloves with a second pair worn over them and sealed to the gown at the wrist with tape, surgical cap, mask, eye protection over my specs and then a visor and a plastic apron.  I remember I was assigned my first covid+ patient who was chatting away to me on admission but sadly deteriorated and slipped away a few hours later, frightened and alone save for the PPE clad pair of eyes holding his hand. This same desperately sad scenario was repeated with the admission of my next patient on that shift also passing away soon after the first. Despite all the best efforts of the staff and medics, and without any specific treatment at that time, patients were dying in our unit and in other healthcare settings all over the world. I’ve never witnessed so many instances of death and so much heartbreak, frustration and despair in my entire 30 odd year NHS career.

I remember the staff who were drafted in to the unit to help. I remember once thinking that a colleague was taking a long time to tie up the back of my gown (it’s just easier!) and when I looked round it was because their hands were trembling. I remember having to give the news no one ever wants to receive to relatives via phone, or by video call, and hearing the last words exchanged between them and their loved ones. I don’t think those words will ever leave me. I remember we had our names written on the front of our gowns so we could identify each other, a small glimpse of humanity in a blue sea of PPE.

There is a floor to ceiling window in CCU which looks out over the entrance to the ED. During the first wave of covid, on a Friday night, we heard a piper and went over to that window. Outside there was indeed a piper along with firefighters, police and ambulance staff looking up at us. We quickly wrote, ‘thank you’ on a piece of paper and stuck it to the window. When the piper finished playing the emergency personnel saluted and applauded up to that window to which we all applauded back down to them. I always tend to get emotional when I hear the bagpipes but never more so than that night.

Returning home from work was another time consuming routine. Taking off clothes I’d worn to work in the garage, sorting my worn uniform and bagging it, straight into the shower without touching anything at all and a litany of other precautions I took to protect my wife, kids and wider family. I would never have forgiven myself if they had become ill because I hadn’t acted appropriately and flouted the rules.

Initially, I only put this down on paper in an effort to get the aforementioned rage out of my system, I think it has. I certainly didn’t write it to garner sympathy or far less, praise. There are many staff who worked on the ‘front line’ during the pandemic for longer than myself. My experiences are in no way unique and will be familiar to a lot of NHS staff. Without getting into the politics of it (those who know me know where my allegiances lie) there is a possibility that some of the people who appeared in the ‘partygate’ video may be honoured and we often hear that we should ‘just move on’ or ‘get over it’. I saw honour in December 2020, I also saw dignity, respect, camaraderie and sacrifice, none of these qualities are apparent in the Downing Street video. I’m afraid I’m not ready to ‘just move on’ or ‘get over it’, not just yet anyway.

Dignity in Continence Care- Working Together by Chris Wallace

The theme of this year’s World Continence Week is ‘ Commitment to Collaboration in Continence Care’ and is a timely opportunity to highlight the excellent work that goes on locally, largely unnoticed, ensuring that patients and their Carers receive appropriate treatment, therapy and care in relation to their bladder or bowel health problems. 

This is only effective because of partnership working- Specialist Bladder & Bowel Nurse Practitioners and administrators, Community Nursing, our general and mental health colleagues in all acute wards and specialism’s, Social Services staff, Allied Health Professionals, Cottage Hospital teams, Community Rehab Team, Paediatric Teams, Ontex Health Care- our current pad provider, Care and Support Workers, Care Home staff, Consultants, GP’s and Primary Care Teams , Carers Centre, Prescribing Teams, National Procurement, catheter companies –the list is endless, all collaborating and communicating , with our patients and their Carers at the heart of their decision-making. 

‘So what!’ you may say. ‘Isn’t that what should be happening?’  Definitely, but nationally, continence care has never been under such significant pressure. With proactive promotion of the service leading to a rise in referrals alongside reduced clinical resources, the increased cost of incontinence products due to Brexit alongside the rising cost of raw materials, and people living longer with life-long incontinence, the focus is understandably on ‘What can we do better, cheaper, slicker?’ and  ‘What can we stop doing altogether?’

What we can do better is never accept incontinence as an inevitability- of hospital stay, of neurological impairment, of mental illness, of being a child with additional needs, of getting older.  

We need to continue to change our culture to one of openness where we are comfortable and confident talking about bladder and bowel dysfunction and possible solutions,  and uncomfortable every time someone automatically views a pad or a catheter as the only possible outcome for someone with new bladder or bowel symptoms.

With a wealth of solutions- focussed resources, these should be a last resort.                            

An Animation on Urinary Incontinence – YouTube

                                                                                                                                                              Also, speedier engagement with patients and their carers when an incontinence issue needs assessed. This is a real challenge when all services are stretched.  However, when continence care breaks down, it can impact catastrophically on all aspects of peoples’ lives, and often precipitates an admission to care homes

Finally, across all our health and social care services, we must promote a healthy bladder & bowel lifestyle, and ensure that people have the right support at the right time to maintain continence.  Only by sensitively asking the awkward questions will we get to the heart of the problem

What we can do cheaper is focus on reducing our spend on pads and other continence appliances  by referring  people with new symptoms- excluding red flags-at the earliest opportunity to our clinics, and reduce waste by ensuring accurate assessments before using containment pads.

What we can do slicker is engage patients and their Carers in self management, sensitively negotiating solutions. That doesn’t mean telling them ‘the continence service say you’re not getting pads’ L  

When people contact us as soon as symptoms occur, there is far more likelihood of a cure or a reduction in the impact of symptoms.     

What we can stop doing altogether is treating incontinence as a taboo, an inconvenience and an unsolvable issue.  Having the confidence to label the use of underpads as an undignified way of managing incontinence, to question why a patient is being discharged with a urinary catheter, which was inserted due to urinary retention, without a trial without it, and to ask when did it become acceptable that ,between care visits, ‘people will just have to use a pad’.

Maintaining continence is complex. Anyone who has ever been severely constipated or had diarrhoea as a result of a change of food, routine or environment, or had the stress of trying to attain toilet training with a child, will have some insight into how difficult it would be to live with this challenge every day of their life.

We have a duty to ensure the right treatment, care and products at the right time for every child and adult living with bladder or bowel dysfunction.

Thankfully, things have moved on a bit since Billy Connolly’s incontinence pants J

Chris Wallace, Service Manager- Community Bladder & Bowel Health Team/ Team Leader- Community Rehab 

Bonding Before Birth by Anna Robson

No one can prepare you for the joys and challenges of parenting and they start long before baby is even born. The love, playfulness, happiness, worry, guilt, pain and sickness start for mum and for baby in the womb. This is a journey you are on together.

I remember the excitement and joy when I discovered I was pregnant for the first time and the pain when it ended in miscarriage. I remember the excitement and joy the second time but also the worry and apprehension, would it be ok this time or would it end in tears again. But then the relief at the 12 week scan, ‘a heartbeat’, ‘a baby’, ‘our son/daughter’.  From that moment, for us, they were a little person growing inside of me, another member of our family who we couldn’t wait to get to know.

And get to know them we did. Even in the womb they showed preferences to music, to food, to times of day. Once I could feel them moving I started to notice patterns. During pregnancy they were always very active before lunch. A pattern which continues now, always getting a bit restless when they are hungry or ‘hangry’ some might say, not too dissimilar to me. 

Through-out my pregnancy I listened to my favourite song most nights before going to sleep, to help me relax. I swear they remember hearing it in the womb and that sense of calm it gave us both back then. Because it always calms them down now when they are getting upset and they too will ask to listen to it before bed when it has been a tough day.

‘Everything grows rounder and wider and weirder, and I sit here in the middle of it all and wonder who in the world you will turn out to be.’ Carrie Fisher, American Actress

My husband was convinced he could hear their heartbeat when he placed an ear on my tummy. As a result he spent much time lying with his head resting on my bump. I didn’t have the heart to tell him it was probably my digestive system. He also stopped telling me about his day, preferring to tell them. I’m not sure if the kicks to his head were a good or a bad thing but I could already tell they were feisty.

Then at 37 weeks my waters broke!!! They just couldn’t wait to meet us and we felt the same. This is a personality trait which has continued, always enthusiastic and impatient, however also a little ambivalent. After going from 0-90 or should I say 0-8cm dilated in a matter of hours they appeared to change their mind. Maybe reconsidering whether they really wanted to leave the only world they had ever know. It’s warm and dark, they never go hungry or thirsty, and they have constant physical contact with you, already their favourite person. They already know your scent, your voice, your favourite music and your favourite food. However after 2 hours of persuasion they arrived. We had a few potential names, boys and girls. But without any conferring with my husband I knew who they were the moment I saw them, ‘Hello Tessa!!’

This was our journey and everyone’s is different. Lots of things can impact on parent’s ability to connect with their baby before birth. Was the pregnancy planned, is the pregnancy wanted, was it the result of a positive relationship? Is it the result of trauma or does it trigger a past trauma? Has this pregnancy come after a series of lost pregnancies or babies or attempts for a baby? Has it come after experience of having a baby on the Neo Natal Unit? Does it feel too scary to believe this baby might make it to full term and arrive safe and sound? Are you juggling the prospect of a baby with a physical illness? Are you managing your own physical or mental illnesses? Is life already stressful? Do you have a supportive partner? Do you have any support? You might be juggling a stressful job, other children, or the role of a carer, poverty, inadequate housing, relationship problems and the list of potential stresses can feel endless. However what I know is that no one commits to the decision to become a parent without wanting to do the best they can. But at this pivotal stage in life we all need a little extra support so it’s important to know where you can get that support from. If you are struggling with your emotional wellbeing during pregnancy talk to you Midwife, Health Visitor, Family Nurse, Obstetrician or GP to discuss support options.

Anna Robson is a Clinical Psychologist at NHS Dumfries and Galloway

June is LGBT+ Pride Month – Why do we need to celebrate? by Anne Allison

Wouldn’t it be great if same-sex relationships were so accepted that they never needed to be remarked on in the first place and there was no need for me to be writing this blog? Sexuality is a spectrum, and we all fall somewhere upon it. Being LGBT+ isn’t weird, different or “other” – it’s perfectly ordinary. I’d like to think we are moving towards a place where most people feel they can live their lives authentically, without having to explain or justify themselves.

Rather than slotting people neatly into boxes, I’d love it if we were all a bit freer; less constrained by the rigid categories of “gay” or “straight”. Myself, I have been in a relationship with my partner (a woman) for 27 years, but if I had to label myself, I’d have to go with the term “pansexual”. I only learnt this term recently, and it refers to someone who is attracted to people regardless of their gender. However, it’s also perfectly normal to find that where you are on the spectrum of sexuality may shift over time. Pansexual is how I feel now, but I am also happy to say there have been times when I would strongly identify as ”straight”, “Bi-sexual”, “gay” or “lesbian”, and may again!

Personally I would love to see LGBT+ status and relationships as being unremarkable, but there’s good reasons why at times it is important to raise awareness and unapologetically celebrate who we are. That’s because the world is not yet there in terms of LGBT+ rights. Attitudes towards members of the LGBT+ community in different parts of the world, or even different sections of our own communities, can still be extremely challenging. We were reminded of this during the World Cup last year which was hosted in Qatar.

Qatar is one of 70 nations around the world that legislate against the LGBT+ community – 11 of these threaten the death penalty. Even in Britain, hateful rhetoric at transgender people (the “T” in LGBT+), on social media and in certain sections of the press, proves how far we still have to go – and prompts a powerful sense of déjà vu amongst the LGBT+ community. For example, Section 28, introduced by the Conservative government under Margaret Thatcher, was only repealed in 2003 and the harm it caused is still very much within living memory. It’s not difficult to draw parallels between how gay people were treated in the 1980’s and 90’s and how the transgender community are targeted today.

Compared to many other parts of the world, the majority of the Dumfries & Galloway LGBT+ community will be grateful to be living openly in a tolerant society which upholds LGBT+ rights. However, we are not completely free from abuse, discrimination or homophobia, and for some people it remains a challenge and a struggle to come out and live fully as their authentic self.

That’s why the Health and Social Care Partnership LGBT+ Staff Network is so important,  providing people with a community of support and a collective voice for change. 

So please forgive us if we choose to shout loud and proud during June, and celebrate Pride Month. We are raising awareness for tolerance and equality for those who can’t. LGBT+ relationships are just as valid and messy and beautiful and “normal” as everyone else’s. Take a moment; learn more about the beautiful, fantastic people, talent and diversity within the LGBT+ community, and celebrate with us.

Happy Pride, wherever and however you choose to celebrate.

Anne.

Anne Allison is Lead Nurse for Community Health and Social Care at NHS D&G and LGBT+ Staff Network Chair

My Mental Health Journey By Liz Forsyth

Many of us will experience mental or physical ill health at some point in our lives or be a Carer for someone who does. I have struggled with periods of mental ill health throughout my life. Not surprising perhaps, when 75% of mental ill health (excluding dementia) starts before the age of 18[1].

The longest and worst period of anxiety and depression I experienced started in my mid 30’s. I can’t pinpoint a day or month as it was a gradual decline. I had a demanding job, was studying for a degree online, had two children and never took a day off sick even when I felt lousy. I was the queen of the fake smile and jovial quip. Only my immediate family knew I wasn’t well and most of them didn’t know the extent of the paranoia, low mood and negative thoughts that I was living with. I was very good at hiding those feelings – until I wasn’t.

Rock bottom

While delivering a self esteem/confidence course (oh the irony!), I had an emotional breakdown because of a text message. It was the last straw in a build up of negative thoughts and experiences. I recently described this as ‘not one specific thing but a million tiny paper cuts’.  

I started crying and couldn’t stop, like really couldn’t stop, couldn’t speak, couldn’t walk, I was curled up on the floor in the corner of a public toilet (gross!), wailing. My husband had to leave work and come and get me. I was inconsolable so he ended up taking me directly to the doctors where they gave me something (I have no idea what) to calm me down and help me sleep.

I had a week off work and then pasted my mask back on, continued to work and study and kid on I was okay. For the next few years I was off and on anti-depressants, and underwent different forms of therapy including CBT, Reiki and 1-2-1 coaching. Some of these interventions were more helpful than others.

My husband took me to New York for my 40^th birthday. We did the works, helicopter ride round the Statue of Liberty, Broadway show, Empire State and open-topped bus. I know I went to all these things as we have photos of me at them. I am smiling but if you look closely I am ‘dead behind the eyes’. I was like a zombie because of the tablets I was on, I felt no emotion, but was very anxious. I have very little recollection of the whole experience and still feel guilty and sad about it, even though I know I wasn’t well.

Taking control/self-help

I decided the medication wasn’t working for me, so with support from my GP I made a plan to come off the medication over a couple of months. I changed my diet, ate more healthily and started jogging. I also completely cut out alcohol. I wasn’t a big drinker but it is a depressant so I wasn’t taking any chances.

Within a few months I had lost weight, was sleeping better, was less paranoid, more confident, more outgoing and generally felt mentally and physically fitter and stronger than I ever had!

I had about 3 years of feeling pretty good but then while studying again, in my mid 40’s, I was beginning to struggle. I put it down to studying really hard and working full time (not having much time to run). However, I was also diagnosed with a learning disability through the university. I realised at that point that this had probably impacted significantly on my mental health and well-being. It explained why I found I had to study much harder than my peers, why I couldn’t cope with exams, couldn’t retain information and why I felt (and still feel) so overwhelmed at times.

Contributing factor

Although I sometimes wish I didn’t have a learning disability/wasn’t neurodivergent, so I could remember things like names/faces, instructions, directions and numbers and didn’t get distracted easily, it is not all bad. I like details (to the point of obsession some might say), can often find solutions or ways to do things which a neurotypical person might not and I am pretty creative. If I wasn’t the way I am, I wouldn’t be me.

Anyway, back to my mental health…

Apart from the unwavering support of my family and friends there have been a few positive influences in my mental health journey but the most significant is definitely running and the friends I have made through it. It is no exaggeration to say running has changed and improved my life. It gives me some control over how I cope/care for myself.

My initial running goal was to do 1 mile without stopping. 13 years down the line, I have lost count of how many half marathons I have done, I have ran about 5 marathons, 1 double marathon and about 4 ultra marathons (generally over 30 miles). I am not saying this to show off, no-one is more surprised than me, and I am still not sure how it happened!

When I started running I was overweight, embarrassed how unfit I was and I hadn’t run since school and that was under duress. I only mention what I have done above because wherever you are in your mental or physical health journey, if you can find some exercise you want to try, whether it is to run a mile, swim a length or do a fitness class, it could end up changing your life.

What works for me

Running is not just about the physical exercise for me, it also got me involved in a fantastic, non-competitive, social running club in Langholm called the Muckle Toon Joggers. I consider some of the members among my closest friends and biggest supporters.

I wish I had found running sooner. Maybe if I had I wouldn’t have ‘lost’ years of my life in the fog of anxiety and depression…

Don’t get me wrong, I still have my ups and downs. I still struggle with sleeping and have days/weeks where I am extremely anxious and feel totally overwhelmed but it is usually because I have allowed work or other commitments to impact on my exercise routine and/or eating habits.

My tools for coping are

• Running 2 to 3 times a week (usually 20 miles total) – rain or shine. Yes, even on holiday
• Eating fairly healthy food (but still enjoying cakes, scones, cheese and dark chocolate in moderation)
• Treating myself the way I would a friend. Would I tell a friend to pull themselves together, you’ve got nothing to be depressed about? No, I would be kind and supportive and that’s what I try to do for myself.
• Not pretending everything is okay when it isn’t
  • Speaking up when things are getting too much
  • Knowing how and when to ask for help
  • Talking to friends and family

Final note:

We are going back to New York this September and I hope to really experience it this time, in full Technicolor, non zombie mode. This time my smile in the photos will be genuine not fake and I will actually enjoy, not dread, each activity. I am taking my trainers so I can run round Central Park!

Some useful resources and info.

If you fancy starting to run, why not check out the Get running with Couch to 5K – NHS (www.nhs.uk)

See Me | CAMHS Participation Be Kind project (seemescotland.org)

Dumfries and Galloway

If you have a disability why not join the Staff Network by emailing dg.disabilitynetwork

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[1] Davies SC. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence

Liz Forsyth is Strategy Support Manager and Co-chair of the Disability Staff Network for NHS Dumfries and Galloway