The C word: care

Posted by Jennifer Remnant & Libby Morrison

I am a carer. I currently work on a ‘casual’ (another ‘c’ word!) basis for a mental health company. Prior to that, I worked chiefly with people with learning disabilities, and also spent some time as a PA to teenage twins with a physical impairment. Being a carer is hard work. Hard, underpaid, undervalued work. It reflects the emptiness of the rhetoric that society (and academia?) uses for service users, and the workforce that supports them. Being a support worker/care assistant/health assistant/personal assistant/care worker can be emotionally and physically draining. It involves the basics; knowledge of food preparation, hygiene and cleanliness and personal care in predominantly tiring shift patterns. If you’re going to attempt to work through Maslow’s hierarchy of needs (which I try my best to do – though it’s a mostly ideological attempt) you need to know how to keep another human being safe, how to feed them and how to keep them clean, whilst also offering service users opportunities to make real choices and where possible maintain personal autonomy, eg; ‘Would you like a piece of cake or an apple?’; ‘Would you like to be obese?’. Carers earning as little as the minimum wage are expected to make difficult and often quick decisions to support service users (often with complex needs) – when trying to balance health and safety considerations against individual choice and autonomy. 

One service user that I used to work with many years ago in a mental health service particularly tested the team I worked in; a typical exchange would be something like this:

Me - ‘Can you go to the toilet please?’

SU - ‘the toilet?’

Me - ‘yep, the toilet’

SU - ‘what for?

Me - ‘to see if you need to go’ (this person is regularly doubly incontinent )

SU - ‘what happens next?’

Me - ‘lets just take this one step at a time’

SU - ‘will I get stuck?

Me - ‘no you won’t get stuck, you didn’t get stuck last time, or the time before’

SU - ‘where do I need to go?’

Me - ‘the bathroom’,

SU - ‘the bathroom?’ (like that is the strangest thing he’s ever heard)...etc.

About 45 mins to an hour after first asking him, he might be on the toilet, he might not. He might go he might not. He might say he can’t, and then when you explained that you had other residents you needed to see and returned to the office, he might follow you there and urinate and defecate there in front of you. Or in the kitchen. Or in the corridor. Which despite not knowing either way, felt like a dirty protest – though in his defence, from macro to micro levels, there was a lot to protest about. 

He moved very slowly a lot of the time, but could also be impressively speedy. His level of understanding was very good, and so was his memory. He liked to talk about sexual violence, especially if it was a locally publicised crime, because then he could discuss with female workers the safety of their chosen route home. He worried about whether staff liked him, and asked them directly. He asked staff if they were his friends. He sometimes called the emergency services in the middle of the night because he woke up terrified that he was going to die. He has been exploited financially throughout his adult life. He was unique. He was witty, funny and thoughtful.

It was harder still to work with this service user when I found out that he regularly found the energy and time to hop into a taxi, travel down to a local brothel and pay for the company of young women. He had a preference for eastern European women. In a painful irony, many of the women service users I work with, especially with the current welfare reforms, have, or do, prostitute themselves.

This man was only one of ten residents in the mental health service he lived in. He started with 24 hour support, but as the money drip-dripped away, so did his support. The team that work with him have not had a pay rise in 4 years because they are not NHS staff.

I think for this example in particular the welfare state and its provisions are an interesting fit. I don’t even know how the staff that work with him now are going to begin to approach the ESA50 form when it comes, or the distress it will cause. In the last 6 months (in a different support role) I have supported various people to fill out ESA50 forms, and despite being as sure as I could be that all would go straight into the support group, the wait was unbearable. All of them smoked, and all of them increased their cigarette intake at this time. A number had to go to the doctors and have their anti-anxiety medication increased and those that drank reported drinking more.

Doing this job highlights the stark difference between the rhetoric at the top and the reality at the bottom. Nothing is packaged up smartly and neatly like some legislation would suggest that it is.

It also forces me to ask big ideological questions about what I’m even doing in a university – and what I want ‘impact’ to mean in terms of research.

Crumbs.

52 weeks of public health research, part 9

Posted by Bronia Arnott, Amelia Lake and Jean Adams

From Amelia Lake: years of hard work condensed into a succinct & excellent presentation. Ashley Adamson introduces Rachel Tyrrell's PhD presentation just before her viva. As one of her supervisors I'm still excited by the research Rachel conducted!

From Jean Adams: a welcome splash of colour on our desk/kitchen table at home reminding us that winter never lasts forever, and that mental well-being is as important as physical health.

From Bronia Arnott: at the train station again on the way to another meeting. Only to Durham for an askfuse meeting this time.

From Bronia Arnott: this is what my commute to work looks like - why not share a picture of yours?

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

The New Public Health System at Nearly One

Posted by David J Hunter

With the public health system changes in England approaching their first anniversary it’s a good time to take stock and reflect. Much remains to be done as new relationships are forged and structures bed down but already some matters are becoming clearer. They pose a mix of threats and opportunities.

The new English public health system has nearly reached its first birthday

It’s in the nature of local government that some local authorities will rise to the challenge presented by public health more readily than others. But to assume that Whitehall, in the shape of the Department of Health or Public Health England, can step in and sort things out is both simplistic and naïve.

As a new report from the Institute for Public Policy Research on the relational state concludes, complex problems defy solution by central government and require all stakeholders, notably local government, to work in new ways to reshape public services. A reliance on bureaucratic and market-based tools is no longer ‘fit for purpose’ if it ever was.

So what are some of the key issues with which the new system is grappling and which will set the future direction in the run-up to the general election in May 2015 and beyond? I briefly explore four here.

Place-based budgeting

The prize in having public health return to local government is the opportunity afforded to adopt a place-based approach to harnessing resources to improve population health across whole communities and neighbourhoods.

Forget the ring-fenced public health budget. This is an often unhelpful distraction and is certainly likely to be time-limited. The real agenda is about pooling local resources from a range of bodies and determining how best to allocate them to meet identified needs.

Already community budgets are being developed in some local areas and there is scope to take this approach much further perhaps picking up from where the Total Place Pilots left off under the last government in 2010.

Role of Health and Wellbeing Boards (HWBs) and managing unrealistic expectations

A paradox of the public health changes is that Health and Wellbeing Boards (HWBs) have acquired huge prominence and expectations are high. They are seen as the system leaders locally charged with the task of promoting integrated health and social care, public health and overseeing the reconfiguration of health services in local areas. Yet they have virtually no powers.

These are significant and complex responsibilities and there must be doubts about HWBs’ abilities to deliver what is needed across all of them. The risk otherwise is that HWBs are being set up to fail. The wiser HWBs will not allow themselves to be stretched beyond their limits and will identify their key priorities and stick to them. Nevertheless, the temptation to take on responsibility for the entire health system will be hard to resist.

Role of Public Health England (PHE)

The new kid on the block is Public Health England and considerable uncertainty surrounds its place in the new architecture, both nationally and locally. Concerns exist over its independence from the Department of Health and this has yet to be thoroughly tested although the omens are not promising.

On minimum unit pricing for alcohol, PHE rested its case on the evidence which ultimately the government chose to ignore. And this is the problem – the evidence rarely speaks for itself. But for a body whose existence is predicated on presenting the evidence what options are open to it should those to whom it reports choose to ignore its advice? ‘Speaking truth to power’ is much more complex and political than simply marshalling and presenting the evidence in the hope that good sense will prevail.

In a new report on PHE, the House of Commons Health Committee is critical of what it sees as an ‘insufficient separation between PHE and the Department of Health’. It concludes that although PHE was created ‘to provide a fearless and independent national voice for public health in England’ it does not believe that ‘this voice has yet been sufficiently clearly heard’.

Local authorities remain wary and puzzled by PHE and the new centres appearing in their midst. They instinctively feel they do not want a central presence overshadowing their work. Conceivably, PHE can offer valuable support and resources but building effective, high trust relationships is proving tricky. It also takes time which is at a premium.

With an election looming in just over a year’s time, PHE will be under growing pressure to prove itself and demonstrate impact. Few cherish ‘quangos’ or arm’s length bodies, especially new ones.

Changing nature of workforce in terms of skills and capacities

Perhaps the most threatening challenge to the public health system, or possibly the one that offers most hope for real progress depending on where you sit in the new landscape, is the public health workforce and the changes which beckon. The issue divides opinion sharply and is intensely political since it confronts long-standing and fiercely held professional views.

There is no doubting that many moving into local government from the NHS are struggling to find their place in the new system. For the most part this comes down to a lack of understanding or appreciation of local government and its political dimension.

The leaders in local government are not the officers but the elected members. Many bring to public health issues considerable extant knowledge and experience of their communities and while this may not represent evidence in the conventional sense, it remains a key factor in decision-making.

I predict that the public health workforce in a few years’ time will look and feel very different. There will be casualties and not all local authorities will get it right but if local government is to serve public health better than the NHS, with exceptions, managed to do, then it’s time for a change in the workforce and its skills base.

The new public health leaders need to be politically astute, able to communicate well with different audiences, form relationships that enable things to get done, and assemble the business case for investing and disinvesting in public health. There are some Directors of Public Health who get it but many still don’t or have no wish to. They live in hope that what has happened to them will, like the floods affecting large parts of England, magically disappear so that life can return to normal.

Looking ahead, the challenges facing public health are hugely complex and require careful assessment and reflection as they unfold. None offers easy answers. While there are risks that the system will be unable to cope and fail to deliver, there is also renewed hope that what is being put in place offers an opportunity to promote health and wellbeing in a way that was only rhetorically advanced prior to April 2013.

52 weeks of public health research, part 8

Posted by Bronia Arnott and Simon Howard

From Bronia Arnott: Healthy snacks for a meeting at the Human Nutrition Research Centre.

From Bronia Arnott: not so healthy snacks when it is my turn to cater a meeting.

From Simon Howard: the newly opened Beautiful Science exhibition at the British Library which charts the history of data visualisation, including a whole (brilliant) section on public health. 

From Simon Howard: this cartogram is from the Chief Medical Officer's forthcoming annual report, which I'm editing. It represents the number of fast food outlets per person at local authority level (darker = more), with the area of local authorities distorted to be proportional to the population. It raises really interesting questions about association with obesity, and shows the complexity of public health - we know there's an association between population density of fast food outlets and deprivation, but there are also weird outliers like Westminster, which is likely related to tourism, and coastal towns, which is likely related to fish and chip shops.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

A blow for translational research – you eat what you (l)earn

Posted by Avril Rhodes and Mark Welford

Congratulations to CEDAR for making the National Diet and Nutrition Survey interesting and fully translated for ordinary people (muggles) like us. Take a look at the February CEDAR bulletin and the infographic illustrating what people eat proportionately more of by income and education, and we guarantee happy hours of wondering who fits into each box, whether the dietary stereotypes you held are correct or not, and dreaming up the ideal meal (culturally) for each sub-group. This is a wonderful case of the picture holding your attention so much more effectively than a written report would do on the same subject, and yet, the picture itself bringing together all kinds of data in one place. A challenge to academics – this is intellectually respectable enough for CEDAR, so what of your Fuse work would lend itself to the same treatment?

Food, income and education: who eats more of what? Foods appear only if they are consumed in quantities significantly greater than that of the UK population as a whole. 

And then you get to the fun part…..

• Fetch my gun, Jeeves. Clearly with all those game birds and smoothies being downed by the high income high education group there must be a new marketing opportunity for pheasant smoothies. Heston, move over!

• And what about the high income, medium education group, tucking into a hazelnut coated prawn or maybe fish rolled in sesame seeds? The boat certainly came in there.

• Having dinner with a professional footballer or Lord Alan Sugar? For the high income, lower education group save all your energies in the menu planning for the pudding – I’d recommend the most wine drenched trifle recipe you can find, or if it’s Christmas a boozy Christmas pudding would be just right.

• The middle of the chart – middle income and mid-range level of education are a real puzzle – average apparently for so much apart from the consumption of spirits and liqueurs, can anyone explain that?

• More tea vicar? The clergy must be in the low paid high educated square given the consumption of buns, cakes and pastries there, the staples of pastoral visits.

• And the Great British aversion to salad looks right.

And the more serious part…..

Some of our pre-conceived ideas are all too obviously supported from looking at the diagrams about consumption of processed meat products on lower incomes, and a greater variety and higher quality foods at the higher income end. As if we needed it another illustration of inequality in diet income related as much as anything else. Bring on the affordable healthy meal!
CEDAR has demonstrated that research findings don’t have to be hidden away in academic journals gathering dust. Research can be communicated in an interesting, engaging, innovative and exciting way. Along with the traditional methods of dissemination through papers, the media, research briefs, case studies, posters and presentations; how about making an impact using animation, podcasts, comics or even comedy?

52 weeks of public health research, part 7

Posted by Bronia Arnott, Martin White, Sarah Morgan-Trimmer and Heather Yoeli

From Bronia Arnott: On my way to a meeting to discuss with public transport providers ways to increase more sustainable travel, but my train was delayed and I was late. Isn't it ironic?

From Martin White: Having been President of the Society for Social Medicine for the last two years and overseen the most radical revamp in its history, it was with some pleasure that I saw its new image revealed on Wednesday 5th February 2014. Please explore the site, look at the new newsletter and submit an abstract for this year's ASM in Oxford.

From Sarah Morgan-Trimmer: This is the new healthy snack table in the office that I share with Annie and Catt at DECIPHer, Cardiff. Public health represented in still life!

From Heather Yoeli: I’ve been doing much of my thinking and writing at the Cowgate Centre, which on Mondays is the main ‘fieldwork site’ for my PhD project. I use the desk beside the main CCTV monitors, and sometimes groups of local kids come over to watch one another making faces at the cameras. This is the scene I returned to after I’d asked one of them to 'look after my things for just a minute’…

From Heather Yoeli: My supervision team have not been excessively impressed with my first attempt at a ‘findings’ chapter for my PhD. And so, on my Thursday day off, I took my children to see the fantastic Judith Kerr exhibition at Seven Stories, hoping to inspire us all with some absolutely brilliant writing. As we shared a hot chocolate afterwards, I saw this stripy gift-wrapped shoebox inviting ‘feedback’ on their café. Giving and receiving an honest and constructive critique of one another’s work is an everyday part of academic life. I do prefer getting my feedback directly…


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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

Protected time

Posted by Jean Adams
When I was medical student, lunchtime training events were held in most hospitals I passed through. The presence of a free lunch made these high priorities for student attendance. However, I think there was only one hospital that put such a high priority on staff attendance that the time was protected – as signalled by a bleep collection at the door. The sessions were specifically for newly qualified doctors in their first year of practice. Staff deposited their bleeps in a basket outside the training room. If any went off during the session, a secretary would respond saying when the session was due to finish and asking that urgent issues were referred elsewhere. At other hospitals, training was something you went to if you had the time and left early if something more urgent occurred on the ward.

When you go to time management training, they always tell you about the important vs urgent matrix. Some things are important but not urgent, others are urgent but not important etc. The idea is that you identify the not important or urgent tasks and get rid of them. Then you allocate your time to the three other groups of tasks ensuring that the important gets done and you don’t end up focusing solely on the urgent. 

Surely there must be some 'pleasant activities' in The Zone?

Emergencies hardly ever happen in research. Which, for me, is part of the attraction. Lots of important deadlines exist – grant applications, conference submissions. But fair warning is generally given, meaning that it is theoretically possible to stop these becoming too urgent. Many, many other things that need attention crop up all the time. Quite often I find these are of the urgent and certainly important to someone else, but not massively important to me variety.

My – not entirely effective – approach to this is to routinely work at home on a Friday. The idea is that this provides me with one full day per week to focus on extended important but not urgent tasks that matter to me – writing papers, reading and commenting on large documents, catching up with the literature. The reality is that I mostly spend Fridays catching up on urgent and some-what important tasks that have accumulated through the week - nudging my me-tasks to next Friday at the earliest.

Sometimes, when my to-do list gets overwhelming (which is admittedly more often than not), I protect other time too. I schedule in a few hours to do a peer review for a journal, half a day to prepare teaching, 30 minutes to make a phone call that absolutely must happen. At the very least this makes me feel slightly calmer that there is definitely time available to do everything. It might also make me slightly more efficient by reducing the number of times I get to my desk with a few free hours ahead of me and have to work out which of the tasks on my list to do next.

But, like making the most of Fridays, the problem with protected time is the self-discipline required to actually do the scheduled task at the scheduled time, and not get distracted by apparently more urgent things. I find this is massively facilitated by having a secretary deal with meeting arrangements and I know that I am exceptionally lucky to have the luxury of even part-time secretarial support. Every time someone asks me directly for some of my protected time I feel I have to weigh up the pros and cons, wonder if their thing is more important than my scheduled thing, make a decision about when the scheduled thing is going to be re-scheduled, feel bad if I ‘choose’ to say no. A secretary, on the other hand, is slightly more remote. Obviously they want to be helpful and will try and fit people in as soon as they can. But they genuinely seem to be consummate experts in just saying no – without explanation or guilt.

This leads me to those pesky people who have worked out that if they ask me, instead of the secretary, they’re more likely to get a yes than a no.

What are your time management solutions?