THE JOURNAL OF THE COMMUNITY PRACTITIONERS’ AND HEALTH VISITORS’ ASSOCIATION
MAY 2018
COMMUNITYPRACTITIONER.CO.UK
I waswas bornborn in the wrong body – God made a mistake 14:2727
Don’t worry, it’s just + PLANT POWER a phase...e... you’ll IS A VEGAN DIET grow out of itt RIGHT FOR CHILDREN? 14:36 PARKINSON’S THE ISSUES WHEN DIAGNOSED UNDER 40
HEALTH LITERACY POLICY, PRACTICE AND NEXT STEPS
IS ANYONE LISTENING?
Trans young people still face stigma & their health is suffering
01 COVER_FINAL.indd 1 27/04/2018 12:21 Cleanse and protect newborn skin from day 1
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*Formulated to minimise the risk of allergies 1 Lavender T, Bedwell C, Roberts SA, et al. Randomised, controlled trial evaluating a baby wash product on skin barrier function in healthy, term neonates. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2013; 42, 203-214. JOHNSON’S® is a partner in the RCM Alliance Programme UK/JOB/16-8100(2)
p02.CPMAY2018.indd 2 25/04/2018 11:30 CONTENTS May 2018 | Vol 91 | No 04
34 COVER STORY 24
‘Trans’ is considered more respectfulul and inclusive than ‘transgender’ or ‘transsexual’
Trans can refer to anyone whose genderr identity does Epilepsy can affect people not completely matchh the sex in different ways they were assigned at birthh
Celebrating unsung NHS heroes 14 40
Is a vegan diet Exploring health suitable for 18 literacy in the UK children?
NEWS 14 BIG STORY 20 VOICE OF A STUDENT 27 DIVERSITY IN PRACTICE Reading you loud and Abigail Swindail: I want A focus on Islam and 7 NEWS IN NUMBERS clear? Improving the to question NHS strategy the impact of religion Your at-a-glance guide UK’s health literacy and culture on practice 21 RIGHTS AT WORK 8 PUBLIC HEALTH LATEST OPINION Sarah Carpenter answers 30 CONTINUING A look at what’s new questions on the new HEALTHCARE 17 THE BIG QUESTION NHS pay framework FOR THE ELDERLY 10 PROFESSIONAL UPDATE Will the ‘sugar tax’ have How to determine Your round-up of the desired positive effect PRACTICE eligibility for NHS- professional news on public health? funded extra care 24 CLINICAL 12 GLOBAL RESEARCH 18 FEEDBACK A cerebral matter – a 33 24 HOURS WITH… Recent findings from Windrush 70 awards, and look at epilepsy and its Alimatu Dimonekene,
COVER: ISTOCK COVER: around the world a call for new trustees links with deprivation anti-FGM advocate
3 COMMUNITY PRACTITIONER | MAY 2018
3-5 CONTENTS/EDITORIAL.indd 3 27/04/2018 12:22 Dippy eggs now safe for all!
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British Lion eggs are approved by the Food Standards Agency to be served runny, or even raw, to pregnant women, young children and elderly people LgÚf\gmlegj]YZgml:jalak`Dagf]__knakal]__af^g&[g&mc
p04.CPMAY2018.indd 4 25/04/2018 11:32 FEATURES
34 COVER STORY Is anyone listening? Young WELCOME trans people face stigma and bullying, and are from Emma, Aviva and Hollie suffering from mental and physical health problems, writes Phil Harris Th e nation celebrated at the end of last month when the third royal baby for William and Kate entered this world. But what kind of world is he entering? One we hope 40 PLANT-POWERED PARENTING with more tolerance and understanding. For this issue, the cover story (page 34) Veganism is no longer a fringe uncovers some startling truths about the diffi culties trans young people are facing, choice – but can children just for being themselves. Th eir physical and mental health is suffering and they’re really be raised healthily on accessing healthcare less often. An alarming 84% of trans young people in the UK a plant-based diet? Radhika have self-harmed. Is there anything you can do as a community practitioner to help Holmström asks a panel of ensure they’re as healthy and happy as they should be? parents and professionals On the topic of raising children – would you, or do you, give your offspring an exclusively vegan diet? Veganism has gone from being an ‘out-there’ option to a RESEARCH mainstream choice, but is it adequate nutritionally for little ones growing up? We cross-examine a panel of specialists on page 40 to help fi nd the answer. 44 ASSISTING YOUNG Health conditions covered this month include epilepsy (page 24) and PEOPLE IN CARE young-onset Parkinson’s (page 48). As our contributor explains, being diagnosed A programme for looked-after with Parkinson’s when children allowed them to you’re mid-career or with increase their self-confidence a young family to support, and build resilience presents a unique set of issues to have to manage. PROFESSIONAL PAUSE Please do let us know what you think of the articles 48 DO I NEED TO TELL MY BOSS? featured, via any of the Writer Tim Carroll highlights channels below, and please the daily struggle of keep on suggesting ideas living with ‘young-onset’ for the future. Parkinson’s, and the role Th ank you in advance... practitioners can play JOIN THE CONVERSATION
aviva@ communitypractitioner.co.uk facebook.com/CommPrac twitt er.com/commprac
Non-member subscription rates Editorial team Printed by Warners Individual (UK) £135.45 Managing editor Emma Godfrey-Edwards © 2018 Community Practitioners’ and Individual (rest of world) £156.45 Deputy editor Aviva Attias Health Visitors’ Association Institution (UK) £156.45 [email protected] Institution (rest of world) £208.95 Assistant editor Hollie Ewers ISSN 1462-2815 Unite-CPHVA Subscription enquiries may be made to Content sub-editor James Hundleby The views expressed do not necessarily Existing Unite-CPHVA members with Community Practitioner subscriptions Professional editor Jillian Taylor represent those of the editor nor of queries relating to their membership Redactive Publishing Ltd Senior designer Nicholas Daley Unite-CPHVA. should contact 0845 850 4242 or see PO Box 35 Picture editor Chloe Crisford unitetheunion.org/contact_us.aspx for Robertsbridge TN32 5WN Advertising Paid advertisements in the journal do further details. 01580 883844 Sales executive Gordana Jevic not imply endorsement of the products [email protected] or services advertised. To join Unite-CPHVA, see [email protected] unitetheunion.org The journal is published on behalf of 020 7324 2735 Unite-CPHVA by Redactive Media Group, Any Unite-CPHVA member wishing Production to change their address or contact Unite-CPHVA is based at 78 Chamber Street, London E1 8BL Production director Jane Easterman 128 Theobald’s Road London WC1X 8TN 020 7880 6200 details must get in touch with their 020 3371 2006 Unite health sector officers local Unite office. Editorial advisory board National officers Sarah Carpenter and Community Practitioner Obi Amadi Lucretia Baptiste Mandy Brimble Colenzo Jarrett-Thorpe Unite-CPHVA members receive the journal Toity Deave Barbara Evans Gavin Fergie Lead professional officers Obi Amadi free. Non-members and institutions may Elaine Haycock-Stuart Brenda Poulton and Jane Beach Gavin Fergie Dave Munday subscribe to receive it. Sarah Reddington-Bowes and Ethel Rodrigues
5 COMMUNITY PRACTITIONER | MAY 2018
3-5 CONTENTS/EDITORIAL.indd 5 27/04/2018 12:22 p06.CPMAY2018.indd 6 25/04/2018 11:32 ◗ NEWS
NEWS IN NUMBERS 1 in 17 elderly residents in long-term care facilities in % Scotland has a healthcare-associated infection 9 (HCAI), according to Health Protection Scotland The drop in the number of school nurses working in Skin and the NHS in England over Respiratory Urine soft tissue the past year, according to NHS Digital statistics. In 2017, there were 2337, 38% 31% 23% compared with 2562 in 2016 and 2675 in 2015
...infections make up the majority of HCAIs
95% were ‘satisfied’ or ‘very 1860ambulance calls in Wales classed as A Prince’s Trust satisfied’ with Wales’ pilot ‘amber’ or non-life-threatening over non-emergency NHS report found 3 winter months took longer than helpline. In its first six 6 hours to respond to, figures show months, it took 71,000 calls. Now the 111 service will 44% of young people in be rolled out across Wales Northern Ireland say they have experienced a Teenagers in the UK are mental health problem 2x more likely to be obese if they recall seeing junk food adverts every day 68% 33% reported compared with revealed they always those who didn’t they always or oft en see any for over or oft en feel hopeless a month feel stressed
Find links to relevant reports and surveys highlighted in the news stories at bit.ly/CP_news_in_numbers
7 COMMUNITY PRACTITIONER | MAY 2018
7 News In Numbers.indd 7 26/04/2018 16:36 NEWS
PUBLIC HEALTH LATEST KEY
SCHOOLS WARNED OF SURGE IN SCARLET FEVER Video Public Health Wales has SYMPTOMS with trends we have seen writt en to schools and INCLUDE A HIGH over the past few years nurseries across Wales to in Wales’. warn them of an increase TEMPERATURE, ‘We have writt en to in the number of cases of schools and nurseries A PINK-RED RASH, Report scarlet fever. WHITE OR RED across Wales to advise The health body them of the signs and received 476 notifications PATCHES ON symptoms of the infection, of the infectious disease in THE TONGUE as it is highly infectious and 476 the first eight weeks of this can lead to outbreaks in notifi cations of the year, compared with 295 in AND SICKNESS young children.’ infectious disease in Campaign the same period last year. Parents concerned the fi rst eight weeks Symptoms include a high Dr Christopher Williams, that their child may have of 2018 to Public temperature, a pink-red consultant epidemiologist scarlet fever should speak Health Wales rash, white or red patches at Public Health Wales, to their GP or contact NHS bit.ly/WAL_scarlet on the tongue and sickness. said the rise ‘is in line Direct Wales, he added. Poll
Website
Government website
Th e UK has the BRITAIN TRAILS BEHIND OTHER WEALTHY COUNTRIES IN INFANT MORTALITY RATES th The UK has the fourth highest at six months in 2010, compared infant mortality rate among 15 with 62.5% in Sweden. The UK has 4highest infant OECD countries (the Organisation considerably more overweight or mortality rate among for Economic Co-operation and obese children than the average 15 OECD countries Development) found an analysis by the among high-income countries, and Nuffield Trust and the Royal College of the second highest prevalence of Proportion of babies Paediatrics and Child Health. babies born with neural tube defects. receiving breastmilk The report found that the UK is now Report author Dr Ronny Cheung at 6 months in 2010 stalling in several key areas such as said the findings ‘should set alarm infant mortality and immunisation bells ringing for policy-makers about levels, and lagging behind most other the effects of cuts to public health high-income countries on mortality, and early years services’. % % breastf eeding and obesity rates. 34 62.5 For example, just 34% of babies in bit.ly/OECD_child_health the UK were receiving any breastmilk
8 COMMUNITY PRACTITIONER | MAY 2018
8-9 li al n s.indd 8 26/04/2018 16: 8 NEWS
£9M BILL FOR CHILD TEETH EXTRACTIONS
More than 5000 children had multiple ‘We have seen a patchwork of schemes teeth taken out in one year in Northern make welcome progress, but what we THOUSANDS OF Ireland, a new study has shown. desperately need now is a joined-up approach.’ UNDER-FIVES The British Dental Association Northern Kirsten FitzGerald, of the Irish Division SUFFER DRUG Ireland estimates that the cost to the health of the European Academy of Paediatric POISONING service of removing 22,699 teeth under Dentistry, said: ‘First tooth, first visit, zero general anaesthetic in under-18s last year cavities – that’s our mott o! Thousands of children under was £9,347,650. ‘As dentists we know this, but evidence five have been admitt ed to Northern Ireland Council chair Roz from practitioners on the ground is that most emergency departments McMullan said: ‘Governments in Wales Irish families are not aware of the benefits of in Scotland aft er being and Scotland have shown there’s nothing early professional oral healthcare.’ poisoned by common inevitable about child tooth decay, and household drugs such as we can’t afford not to put those lessons bit.ly/NI_extractions paracetamol and ibuprofen. into practice. Accidental poisonings were the second most common reason, aft er falls, for under-fives ending up in A&E last year. More than 3000 needed emergency treatment for this reason since 2011 – including 532 in 2016-17 alone. The figures, compiled by the Information Services spent removing 22,699 Division Scotland, reveal that more than half – 290 – were teeth under general caused by drug poisoning, including 149 with painkillers. anaesthetic in under-18s Dr Steve Turner, officer for Scotland for the Royal College of Paediatrics and CHILDREN WITH SPEECH PROBLEMS Child Health, said: ‘This data NOT RECEIVING ADEQUATE HELP highlights the number of young children who have Children are not gett ing the support therapy was available as required. Only 12% had their lives unnecessarily they need for speech, language and said their child’s communication difficulties put at risk because they communication needs (SLCN) in England, were flagged by a relevant professional. have managed to get hold a review has concluded. The report says: ‘Poor understanding of household products, The report, Bercow: ten years on, of and insufficient resourcing for SLCN particularly painkillers.’ created by children’s charity I CAN and the mean too many children and young people Royal College of Speech and Language receive inadequate, ineffective and bit.ly/SCT_poisoning Therapists, looked at progress over the inequitable support, impacting on their past decade. It says that a disjointed educational outcomes, their employability system is failing thousands of children by and their mental health.’ not identifying their needs early enough or I CAN chief executive Bob Reitemeier providing adequate support. said: ‘Too many children with SLCN are It incorporates a survey of more than being missed by the system, and this is a 600 parents, revealing that more than half national disgrace.’ had to wait longer than six months for their child to get the help they needed, and just bit.ly/ENG_Bercow 15% said they felt speech and language ISTOCK
9 COMMUNITY PRACTITIONER | MAY 2018
8-9 li al n s.indd 9 27/04/2018 12:22 NEWS
PROFESSIONAL UPDATE
‘We look forward to sharing what we have learned, and to learning from others about how to make Wales an even better 682 place to live’ children UNITE CALLS FOR MORE HV SHORTAGE DENIES NEW COLLABORATING SCHOOL NURSES TO CHILDREN CRITICAL CENTRE FOR HEALTH IMPROVE MENTAL HEALTH HEALTH REVIEWS INVESTMENT OPENS
‘Enforceable targets’ Almost 700 one- and WHO has designated for school nurses must two-year-olds have failed Public Health Wales’ be included in the government’s to undergo an annual health visitor Policy, Research and International green paper on children and young review because of a staff shortage at Development Directorate as a people’s mental health provision. the Western Health Trust. Collaborating Centre on investment This is one of the calls from Unite, Toddlers living in Derry/ for health and wellbeing. responding to the consultation on the Londonderry, Limavady and This, the first WHO green paper, which closed in March. Strabane are the worst affected. Collaborating Centre in this area The union has called for the A total of 682 children did not of expertise in the world, will government to increase the number receive either a first- or second-year develop, collect and share new of school nurses, which has fallen assessment over approximately a information on how to invest in by 20% – or 616 – across the NHS two-year period. bett er health, reduce inequalities since 2010. Weekend clinics are now using and build stronger communities in It also warned that the uplift in the health visitors from all over the trust Wales, Europe and worldwide. number of health visitors brought in to address the waiting lists within a A four-year programme of under the coalition government was three-month period. work with the aim of informing at risk of being ‘wiped out’ because The trust said that cases have evidence-based interventions and of cuts by local councils. been prioritised and that no child sustainable policies intends to Unite’s lead professional officer was at risk. Bob Brown, the trust’s support the health and wellbeing for mental health Dave Munday executive director of nursing, said: of current and future generations. said: ‘The government needs to ‘We are very confident that every Professor Mark Bellis, director broaden the scope of its ambition child who is of a higher level of need of the new centre, said: ‘We are with an increased focus on early has been assessed, their reviews are looking forward to sharing what years support. Ministers also need to up to date and that those who are we have learned, and to learning boost school nurse and health visitor delayed will be seen quickly.’ from others about how to make numbers to improve mental health Eight new health visitors will take Wales an even bett er place to live, and wellbeing outcomes.’ up their posts in September. work and raise a family.’
bit.ly/ENG_mental_health bit.ly/NI_reviews bit.ly/WAL_WHO ALAMY / ISTOCK
10 COMMUNITY PRACTITIONER | MAY 2018
10-11 ssi nal n s.indd 10 26/04/2018 16: 9 NEWS
NHS staff increased by
1880 22.5% between 2016 of Blackpool’s and 2017 population smoke
FRONTLINE STAFF REACH NHS PAY DEAL WILL BE BMA PLEADS FOR END RECORD NUMBERS MATCHED IN SCOTLAND TO FUNDING SQUEEZE
The number of people Scott ish NHS workers will see Public health funding is working on the frontline their pay boosted at least as not meeting local needs, in the NHS in Wales is at a record much as their counterparts south of the and cuts should be reversed, a British high, according to latest statistics. border if the UK Government’s new pay Medical Association (BMA) report More than 90,000 people are deal is accepted Staff Side. has found. now employed, up by 1880 since The pay rise of at least 6.5% over The report, Feeling the squeeze, 2016, including nurses, midwives, three years – which could be as high as analyses the effects of changes to consultants and ambulance staff. 29% for some – will be passed on to staff public health funding. Figures released by the Welsh in Scotland, the Scott ish health secretary It cites Blackpool Council’s end to Government also show that the Shona Robison has confirmed. funding smoking cessation services, total number of full-time equivalent Staff affected include nurses, despite the fact that 22.5% of the (FTE) directly employed NHS staff midwives, paramedics, scientists, porters town’s population smoke, far higher increased by 2.1% over the last year and cleaners. Higher-paid workers, such than the 15.5% national average. to 77,917, up from 76,288 in 2016. as consultants and senior managers, are Lambeth Council cut funding for Over the same period, the number covered by separate agreements. sexual health services by more than of FTE qualified nurses, midwives and Robison said the lowest-paid staff 85% between 2016-17 and 2017-18, health visitors rose 0.6% to a record in Scotland are already paid more although the level of new sexually high of 22,612. because of the Scott ish Government’s transmitt ed infections was the Health secretary Vaughan Gething commitment to pay the National Living highest in England. said the government would continue Wage to all employees. But she said The BMA report says: ‘Access to to invest in NHS education. all staff covered by the agreement vital public health services is being ‘NHS bursaries for student ‘will be paid at least as much as their substantially reduced in some nurses, midwives and allied health counterparts in other parts of the UK’. local authorities that have high professionals in Wales will continue Negotiations between government levels of deprivation. Cutt ing these – demonstrating our commitment to and Staff-Side unions in Scotland will services is likely to further undermine ensuring the health service has the start in the coming weeks, aft er which efforts to tackle health inequalities staff it needs for the future,’ he said. any offer will be put to a member ballot. across England.’
bit.ly/WAL_staff bit.ly/SCT_pay_deal bit.ly/ENG_BMA
11 COMMUNITYCOMMUNITY PRACTITIONER PRACTITIONER | FEBRUARY | MAY 2018 2018
10-11 ssi nal n s.indd 11 26/04/2018 16:40 NEWS
For more information on these studies, visit GLOBAL RESEARCH the bit.ly links
USA ANTACID USE DOUBLES BABY ALLERGY RISK Babies who are given antacids or antibiotics during their first six months may be at a higher risk of developing allergies or asthma, a new study has found. Researchers led by the Uniformed Services University of the Health Sciences in Maryland analysed 792,130 children. Children given antacids as babies had double the risk of developing allergies to foods such as peanuts and eggs compared with those given none. They were 70% more likely to have a medication allergy and had a 50% higher chance of developing hay fever. In children given antibiotics as babies, the likelihood of developing asthma or an allergy to cow’s milk or eggs was more than doubled. The study, published in JAMA Pediatrics, concludes that these drugs ‘should be used during infancy only in situations of clear clinical benefit’.
bit.ly/PED_antacids USA ARGUING PARENTS CAUSE LASTING EMOTIONAL DAMAGE TO CHILDREN Conflict between parents can impact on their children’s emotional processing, new research shows. USA The study from the University of Vermont, published CHILDREN WITH AUTISM AT INCREASED RISK in the Journal of Personal and Social Relationships, OF VACCINE-PREVENTABLE DISEASE assessed 99 children aged between nine and 11 who were Children with autism and their younger siblings are less shown photographs of couples engaged in happy, angry likely to be fully vaccinated, a study shows. or neutral interactions, and asked them to choose into More than 3700 children with autism spectrum disorder which category the photos fit. (ASD) and almost 500,000 children without, were studied. While children from low-conflict homes consistently Researchers found that, aft er children received an autism categorised correctly, those from high-conflict homes diagnosis, rates of vaccination were significantly lower were less able to correctly identify the neutral poses, suggesting that they were hypervigilant and on edge. (82%) compared with children of the same age who did not Alice Schermerhorn, lead author of the study, said: ‘No have an autism diagnosis (94%). The study, published in JAMA Pediatrics, one can eliminate conflict altogether, but helping shows the proportion of younger siblings who children get the message were fully vaccinated was also lower among that, even when they argue, siblings of children with ASD. parents care about each other and can work bit.ly/PED_autism things out is important.’
ISTOCK bit.ly/JPSR_conflict
12 COMMUNITY PRACTITIONER | MAY 2018
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FINLAND MOTOR SKILLS ENHANCE READING IN OBESE CHILDREN A new study has linked high percentage and a higher during early childhood may body fat in boys to poor concentration of leptin, a contribute to reading skills in reading skills, but suggests hormone secreted by fat, boys during the first grades this can be mediated by was associated with poorer of primary school.’ bett er motor performance. reading skills in boys – and In girls, higher levels of an Researchers investigated these associations were enzyme marker of a fatt y the association between explained by poorer motor liver was inversely related to cardiometabolic risk factors skills that oft en accompany reading fluency. with academic performance higher body fat levels. The findings were published in the Journal in 175 Finnish children aged Author Dr Eero Haapala of Sports Science. between six and eight. of the University of Jyväskylä A higher body fat said: ‘Motor skill training bit.ly/JSS_reading_skills
ENGLAND CHILDREN IN CHARGE OF UNHEALTHY PACKED LUNCHES Children are persuading parents to fill their lunchboxes with sugary and fatt ening treats, according to research. The University of Leeds study, which involved 20 parents of five to 11-year- olds, found their biggest motivator when packing a child’s lunch was their child’s food preferences. The research, published in the Journal of Nutrition Education and Behaviour, indicates that children made specific requests AUSTRALIA when shopping, or the parent BIRTH INTERVENTIONS LINKED packed what they knew would be TO LONG-TERM HEALTH enjoyed and eaten, rather than PROBLEMS IN CHILDREN what was healthy. A study has linked medical interventions at birth The parents in the study also with a higher risk of health conditions such as questioned how far school rules jaundice, respiratory infections and eczema. over unhealthy lunch choices were Researchers looked at data from 491,590 effectively enforced. healthy women and their children born in New ‘Children’s role in their packed South Wales between 2000 and 2008. lunch provision highlights their Those born by spontaneous vaginal birth growing authority over everyday food had fewer short- and longer-term health decisions,’ said Dr Hannah Ensaff, problems, compared with those born aft er birth who led the research. She said it has interventions, according to the study published implications ‘for staff involved in in Birth journal. providing school food and presents For example, babies born by caesarean section an opportunity to develop initiatives (CS) had higher rates of hypothermia following to promote bett er food choices and birth, and those born by emergency CS had subsequent nutrition’. the highest rates of metabolic disorders – such bit.ly/JNEB_lunch as diabetes or obesity – in later life.
bit.ly/BIRTH_intervention
13 COMMUNITY PRACTITIONER | MAY 2018
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READING YOU LOUD AND CLEAR
ealth literacy is long-term health conditions (Public defi ned by WHO Health England (PHE), 2015). And as ‘the personal it is more likely to be an issue for H characteristics and disadvantaged groups, and those social resources with poorer general literacy and needed for individuals and numeracy (PHE, 2015). communities to access, understand, Not only does it have a potentially appraise and use information and devastating impact on individuals services to make decisions about who are at risk of problems such health’ (WHO, 2014). as misusing medications or Simply put, health literacy enables exacerbating chronic conditions people to understand and use health such as diabetes, but it also drains information and services well enough NHS resources: the economic cost to actively take care of their health. of poor health literacy in England is And while it is largely dependent estimated at between £2.95bn and on literacy levels in the population, £4.92bn a year (PHE, 2015). health literacy is a two-way street, with the onus on healthcare providers HOW HEALTH to present information in a clear and LITERATE ARE WE? comprehensible fashion. Poor health literacy is surprisingly common. Th e European Health WHY IS HEALTH Literacy Survey found almost one in LITERACY IMPORTANT? two respondents had insuffi cient or Fundamentally, poor health literacy problematic health literacy (Sørensen leads to poorer health. WHO et al, 2015). A study in England recognises it as ‘a critical determinant showed 43% of working-age adults in of health’ (WHO, 2016) requiring England were unable to understand investment for its development, and and make use of everyday health the American Medical Association information (Rowlands et al, 2015). (AMA) concluded that health literacy Professor Jo Protheroe, chair of is a stronger predictor of health status Health Literacy Group UK, who than age, income, employment co-authored that study, says it status, education level, race or ethnic included a range of health-related group (AMA, 1999). information, including reading Limited health literacy is linked instructions on the side of medicine with unhealthy behaviours and packaging and directions on how poorer health outcomes; those with to fi t a car seat, to assess how well limited health literacy are more subjects matched the literacy and likely to use emergency services, and numeracy skills of the working-age less likely to successfully manage population in England.
14 COMMUNCOMMUNITYITY PRPRACTITIONERACTITIONER | MAMAYY 2018
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‘What we found was a mismatch,’ and action plans highlighting the she says. ‘Th e information out there issue: for example, Scotland’s is too diffi cult to comprehend for Making it easier, published last nearly half of working-age adults. year, which set out strategies to And if you include numbers – say, embed health literacy in policy on the side of a bottle of Calpol to and practice throughout health calculate the number of millilitres and social care services (Scottish appropriate for a child – that rises to Government, 2017). 61%. Th at equates to between 15 and In England the latest advance was 21 million working-age people across the launch, in December last year, of TOP HEALTH the country.’ a health literacy toolkit, developed LITERACY TIPS by Health Education England (HEE) WHAT CAN BE DONE? in partnership with PHE, NHS Don’t make any Professor Protheroe believes health England and the Community assumptions about literacy is not solely down to the Health and Learning Foundation literacy levels skills of the individual, but about the (HEE, 2017). and understanding. balance between their skills and the It includes a number of strategies environment – the health, education to help healthcare workers adapt Use the teach-back and care systems they navigate. their practice, including the much- technique – asking She insists the onus must be on lauded teach-back method, which someone to repeat back healthcare professionals to ensure works by asking people to repeat what they have just been that they communicate with patients back to health told to assess their level in ways that can be understood. professionals of understanding. ‘We have consistent evidence that what they have LIMITED HEALTH low health literacy can be improved just heard as a LITERACY IS LINKED Make use of diagrams through moderating communication way of confi rming and pictures. and making changes to the clinical understanding. WITH UNHEALTHY environment,’ she says. Th ere is also a BEHAVIOURS Stick to three ‘And if you improve health literacy, dedicated toolkit AND POORER points rather than you improve outcomes. You improve for school nurses, overloading someone medication use, you improve produced by the HEALTH OUTCOMES with information. self-management of conditions, Association for reduce mortality, reduce unplanned Young People’s If you have to give emergency visits, reduce hospital use Health (AYPH) with the support of more information, use and improve screening.’ PHE (AYPH, 2016). the ‘chunk and check’ Among the notable initiatives in technique, giving a small POLICY AND PRACTICE Northern Ireland are those taking amount of information, With NHS services under place within Belfast Healthy Cities, then checking that it has unprecedented pressure, the part of the WHO global Healthy Cities been understood before drive towards increased patient project, where work has included moving on. participation, self-care and self- creating online resources and health management shows no sign of literacy training. Belfast also hosted Look out for ‘red flags’ abating – but, as experts have the Health Literacy: Making Life in patients such as pointed out, if health literacy isn’t Better UK conference in February body language, missing also addressed, that policy goal could this year. appointments, being actually worsen health inequalities slow to fill in forms or (Protheroe et al, 2009). NEXT STEPS questionnaires, finding So what is being done to ensure Louise Hales, chair of the CPHVA it difficult to give a UK populations are properly in Northern Ireland and a lecturer coherent history or not empowered to manage their own at Queen’s University Belfast, says asking many questions. health and wellbeing? efforts are still very much focused Health literacy is already on raising awareness. Make sure you use embedded in policy across the ‘I think until the message is out everyday language and four nations, with scoping studies there that this is a signifi cant public not medical terminology.
15 COMMUNITY PRACTITIONER | MAY 2018
14-16 BIG story.indd 15 26/04/2018 16:43 NEWS
health issue, things won’t improve. pharmacists, GPs and dentists. HARD TO GRASP? It’s in policy documents, but I don’t ‘We need to be training all staff think it’s reached practice yet.’ to recognise whether there could She adds: ‘It is something we really be issues with somebody’s health need to be more mindful of when literacy, as well as working with the having any interaction with patients community and the voluntary sector – whether we are providing them to raise their awareness, so that they with information or asking them to can initiate programmes to support participate in their own care, make people,’ she says. decisions about treatment or follow ‘And we as practitioners need a regime. to make sure we are working in a ‘We need to recognise that we person-centred way.’ can’t leave it all down to the % individuals. Yes, measures need to 43 of working-age adults be taken to improve people’s RESOURCES in England are unable education and literacy levels, but to understand or organisations, governments and Making it easier health make use of everyday practitioners have a responsibility to literacy action plan health information ensure they make the information bit.ly/SCT_health_literacy understandable, and that includes everything from signs in hospitals Health Education England’s to information leafl ets. And there health literacy toolkit are things that can be done in bit.ly/ENG_health_literacy appointments, such as the teach- back technique.’ Public Health Wales’ Louise is also a member of the scoping document intersectoral Health Literacy bit.ly/WAL_health_literacy Working Group, which aims to 61% raise the profi le of health literacy Belfast Health Cities’ of the same fi nd health across all sectors in Northern health literacy toolkit materials containing Ireland. Th is work is supported by bit.ly/NI_health_literacy both text and fi gures too complex to understand the Belfast Healthy Cities project, which also delivers communication training focused on health literacy For full references, visit to community agencies and health bit.ly/CP_news_big_story up to 21 professionals, including community million adults in England have poor health literacy
Th ose with poor health literacy are 1.5 to 3x more likely to experience depression, increased hospitalisation or die PHE, 2015; Rowlands et al, 2015
16 COMMUNITY PRACTITIONER | MAY 2018
14-16 I s .indd 16 26/04/2018 16:44 OPINION
THE BIG THIS MONTH WE ASK Will the ‘sugar tax’ have the desired positive effect QUESTI? N on public health?
SARA PATIENCE BARBARA POTTER AMY STEEDEN-SMITH Bank health visitor and Associate lecturer of a third-year Specialist community public registered nutritionist working undergraduate course module health nurse/health visitor in south-west London at the Open University working in Blackpool
vidence he logic for a he idea of E suggests tax on sugar T taxing sugar that sugar- T to reduce products is sweetened drinks (SSDs) consumption, improve not a new public health have a deleterious health and raise revenue concept and already effect on public to fund healthcare operates in other health. Th ere is an seems compelling. But countries. It could be association between would it work? argued that health greater consumption of SSDs and an Health-related food taxes have been systems and cultures in these countries increased risk of type 2 diabetes; and the introduced in Hungary, France, Finland, differ greatly to the UK, however, a report consumption of SSDs in children resulting Mexico and some states in the USA. Th ey by WHO (2015) has endorsed sugar tax, in greater weight gain and increased BMI raise revenue, but there is no data yet on promoting lowering rates of obesity, tooth compared to consumption of non-SSDs. whether it can reduce consumption long decay and improved health outcomes. SSDs are one of the main sources of sugar term. It’s a complex picture. Nonetheless, the sustainability of in a child’s (11-18 years) diet (SACN, 2015). Small changes in prices affecting health behaviours through a tax rise Other countries including Mexico have high-income groups tend to have little alone is questionable. Prochaska and already introduced a sugar tax. Analysis impact on consumption. But low-income DiClemente (1983) would suggest that from Mexico demonstrates a reduction populations are more sensitive to them when an individual changes their sugar in the purchase of soft drinks with the because they spend more of their income diet, they require health promotion and greatest reduction in disadvantaged on food; they also buy more high-energy education throughout their journey from groups (PHE, 2015). foods from cheaper, less healthy sources precontemplation to avoid a relapse and Th e sugar tax is intended to be one of so they feel the impact more (Gao, 2012). to promote sustainability. Diet and health a number of solutions to reduce obesity, But this doesn’t take food preferences behaviours, may be inter-generational, not a solitary panacea. In my opinion, it is into account. and deeply ingrained within cultures, worth trying. Sugar is not a nutrient and Heavy consumers of sugary foods are meaning individuals may be reluctant to there is no harm in reducing sugar intake. far less responsive to price changes than change their eating habits. Although there is concern that the moderate consumers, which weakens While some individuals may be sugar tax will hit disadvantaged groups the consumer welfare argument. Th ey shocked into action by price increases the most, the intention is to encourage may also buy alternative cheaper foods of sugar, others may pay the higher levy SSD manufacturers to reduce sugar in instead which may be unhealthier, like for favourite products that they consider their products or reduce portion sizes, chips covered in salt; or continue to buy essential or staple within their diet, similar rather than pass costs onto consumers. the expensive food and fewer healthy to alcohol and tobacco. Th is may lead to Even if you don’t believe it will foods (Green et al, 2013; Bonner and further inequalities and deprivation within reduce obesity, remember that sugar Requillart, 2011). society. Th e impact of the tax within the consumption is a leading cause of tooth Tax is not a simple fi x that will UK remains to be seen, but it's clear that decay, and that in England a child has a improve health without many other there is a need for continuing investment tooth removed through decay once every environmental social and cultural in public health services, such as health 10 minutes (PHE 2018). Th at’s enough to considerations affecting our food choices visiting, in order to have the desired effect convince me. (Jensen and Smed, 2013). of improving health outcomes in society.
17 COMMUNITY PRACTITIONER | MAY 2018
17 i .indd 17 27/04/2018 12: 2 OPINION
FEEDBACK
CELEBRATING THE UNSUNG BME HEROES
n the morning of 22 reach the fi nal line-up. You June 1948, just two can show support for weeks before the nominations online up until O NHS was launched, 11 May. Registration for the the cruise liner Empire Windrush ceremony will open soon. Th e docked at Tilbury, carrying 492 nomination categories include: passengers from the West Indies. Some of those passengers were NHS lifetime achievement among the fi rst people to work in award (sponsored by the NHS. NHS England) In the years since, many Research and policy more people from around the development (sponsored by world have come to work in the Health Education England) NHS. Today, people of black Clinical excellence for and minority ethnic (BME) allied health professionals backgrounds make up a fi fth (sponsored by the Care of its workforce. Quality Commission) Rising stars innovation OUTSTANDING SERVICE (sponsored by NHS Digital) To celebrate this diversity, Contribution towards the Windrush 70 Awards will improving health inequalities acknowledge a wide range of (sponsored by Public clinical, research and leadership Health England) achievements, as well as the BME inspirational unsung heroes who might leader (sponsored by otherwise be overlooked. NHS Improvement) NHS workers have nominated Top leadership (sponsored by their colleagues, while patients the NHS Leadership Academy) and service users have nominated Clinical excellence for medics the workers who have cared for (sponsored by the British them or a member of their family. Medical Association) Th ere are many inspirational stories of outstanding patient Th is is a great opportunity to care, and of NHS staff who have celebrate the achievements of one made a real difference. of the nation’s most treasured and THE AWARDS WILL ACKNOWLEDGE A diverse institutions, to appreciate the LOOKING FOR WINNERS vital role it plays in our lives, and to Th e most supported nominees will WIDE RANGE OF CLINICAL, RESEARCH recognise and thank NHS staff – the make it onto the shortlist, and the AND LEADERSHIP ACHIEVEMENTS, AS everyday heroes. winners in each category will be WELL AS THE UNSUNG HEROES WHO announced at the awards ceremony To ‘support’ nominations in Manchester on 12 June. We hope MIGHT OTHERWISE BE OVERLOOKED and for more information, visit
that some CPHVA members will windrush.crowdicity.com GETTY
18 COMMUNITYCOMMUNITY PRACTITIONER PRACTITIONER | |MARCH MAY 2018 2018
18-19 d a .indd 18 26/04/2018 18:16 OPINION
A SEARCH FOR NEW TRUSTEES
Th e CPHVA Education and Development Trust the development of practice. Th e charity is recruiting up to three new trustees, and is funds several awards and bursaries for CPHVA looking for people with a fi nancial or professional members, including: background. Suitable candidates will: £20,000 every year for research or KATE GAYLE via Twitt er Understand the role of community nursing professional/academic study to enhance @gayle_kate and its public health contribution public health practice @CommPrac I totally Understand the role and responsibility of 10 tickets to the annual CPHVA professional agree with Rekha’s vision... being a trustee of a registered charity conference for the newly qualifi ed or those as an HV I am concerned Have experience of committee work who have not attended conference before Have excellent communication and Travel bursaries of up to £2000 for public about service provision interpersonal skills health work abroad and how we can meet the Be impartial, fair and able to Best poster prizes at the Unite/CPHVA annual expanding needs of our respect confi dences professional conference worth £125 each. families. #futureCP Bring additional skills, knowledge, ideas and experiences to the committee. THE ROLE OF TRUSTEES Th e trust currently has seven trustees and a THE EARLY INTERVENTION ABOUT THE TRUST professional offi cer. Th e administration of the FOUNDATION via Twitt er Th e CPHVA Education and Development Trust awards is delegated to the professional advisory @TheEIFoundation was set up in 1997 with a bequest from Dr Ian committee, which reports to the trustees. MacQueen, a vice president and trustee of the Th e trustees usually meet four times a year @CommPrac features on former Health Visitors’ Association (HVA). – at the AGM during the CPHVA professional the mental health He believed that health visitors make a vital conference, once in London, and two other dividend by EIF senior contribution to the nation’s health and wanted times by teleconference. adviser @steph_wadd to support their work. If you are interested in becoming a trustee, Available for members at Th e Trust registered as the CPHVA Charitable send vice-chair Kitty Lamb a brief outline of communitypractitioner. Trust but changed its name in 2004 to refl ect your background and the benefi ts you feel you co.uk its main work – giving awards for excellence could bring to the trust at kitt [email protected]. in practice and education, and supporting Th e closing date for applications is 31 May 2018.
MICHELLE MOSELEY via Twitt er @shel_e_moseley Great to see Helen THE HVOPC – HERE TO HVOPC, which includes raising Knapman’s article in this and discussing the issues that month’s Community HELP REPRESENTATIVES are important to their regions. Practitionerr. Well done! ANGELA LEWIS Members often ask how to get ISSUES THAT MATTER KEY QUESTIONS via Twitt er more information or support At these meetings they How do I join? @angelabinkee2 from colleagues across the talk about campaigns, Representatives are elected union. One answer is the Health industrial issues and other at the regional health Just read my Visitor Organising Professional areas of interest. Th is way conferences in the spring. Committee (HVOPC). representatives learn more @CommPrac journal Th e HVOPC is here to help. It about the national and What if I’m new? well done all brings together representatives local developments that are Any representative, regardless informative, feels from around the country affecting their regions, so of their experience, can bring who have been elected at the they can provide even better information and ideas. very fresh and no regional health conferences. support to their colleagues. formula feed adverts Th ese representatives attend All representatives are Who can I talk to about this? #result @ObiCPHVA four HVOPC meetings a mentored and supported to Th e chair of the HVOPC is year with all the other ensure they are able to take Annie Hair. You can email her @GavinFergieg regional delegates. a full and active part in the at [email protected]
To give any feedback on the journal (or even to show us how your team enjoys reading it), email [email protected], tweet us @CommPrac, or reach us on facebook.com/CommPrac
19 COMMUNITYCOMMUNITY PRACTITIONER PRACTITIONER | |MARCH MAY 2018 2018
18-19 d a .indd 19 26/04/2018 18:17 VOICE OF A STUDENT ‘I WANT TO QUESTION NHS STRATEGY
ABIGAIL SWINDAIL Flying Start health visitor, studying MSc strategic DECISIONS’ leadership at the University of South Wales the medical jargon back Th is course has so far @FatLassRuns SCHEDULING A in the fi rst year of nurse enabled me to question training. My student STRESS-RELIEVING strategy, investigate the colleagues are from RUN HAS A business roots of decisions n MSc was always various health and social care GREAT EFFECT made and analyse the process on the cards as backgrounds, providing us all from a practitioner and A I’m someone who with new perspectives on our ON MY ABILITY business perspective. While likes to ‘indulge’ in academic roles and on the organisation TO CONCENTRATE it has been diffi cult to get to study (read ‘glutton for as a whole. We are all in the grips with the concepts, once punishment’) every few years, same circumstances, and it I have understood them I to keep the grey matter fi ring. is comforting to know that, off tasks, but I don’t worry have found it very interesting I was adamant that I didn’t as such a small cohort, we unduly when life throws to look between the lines of want to follow the traditional are also all supportive of a curveball. strategy within the NHS. public health approach – I each other. Business and the NHS may needed something different, Being a part-time student IMPROVING PRACTICE sound boring, but this is not something to create my working full-time requires a I like to know ‘why’ we the case: I am questioning my ‘USP’. I searched for the right great level of commitment, do things; I’m sure my practice, improving it and programme for two years which is why I would advocate mum can attest to my seeking to make changes for before fi nding something waiting for the right course to inquisitiveness as a small my clients by streamlining that fi tted the criteria I come along. Studying has had child, and it is no different in processes within my role needed: part-time (distance a huge impact on my life and my professional life. Within as a health visitor. I can see or taught) and business- and has created some challenges in the NHS we are governed potential for changes to be health-related. my work/life/study balance, by procedure, policy and made within a service and will Th e strategic leadership but these are challenges strategy; I want to know strive to make my voice heard MSc I am studying is a new and which, when fi nished, why and fi nd out more about so I can be an advocate for our innovative course marrying a will doubtless be worth it. where the decisions are made clients to have the best service business approach to health Sometimes, scheduling a and who makes them. that we can deliver. and social care settings. Once stress-relieving run has a the application was completed great effect on my ability Further study – what I’ve learned and the place successfully to concentrate; studying gained, the next hurdle was the isn’t about hitting the books Don’t be afraid to apply for grants and funds fi nancial implication of a three- constantly, but digesting and to assist with postgraduate study. It really is year MSc – cue applications for processing already-known worth it grants and funding. information. Organisation, If the right course isn’t available, wait for one Th e course comes with a however, is key. I am all in But don’t be afraid to explore alternative new lexicon to learn, akin to favour of lists and ticking courses, which are still relevant to practice.
20 COMMUNITY PRACTITIONER | MAY 2018
20 i as d n .indd 20 26/04/2018 17:01 OPINION
RIGHTS AT WORK MEMBERS HAVE THEIR SAY ON NHS PAY Unite’s head of health Sarah Carpenter answers questions raised by Unite members on the negotiated NHS pay framework.
Will any increases able to make a case for additional pay awards WHAT NEXT? to 2018-19 pay be to ensure that NHS pay doesn’t start falling backdated if the behind again. Unite’s national health pay framework committ ee made a is accepted by What happens to incremental dates under the decision to consult with union members? proposed deal? Will these be changed? members on the deal and If a deal is No. Everyone will retain their existing recommend acceptance. reached, any incremental dates. For new entrants to the All members in England pay award will NHS, their incremental date (or pay-step should have received be backdated date), will be the date that they join the NHS. ballots on 30 April and to 1 April 2018. must return votes by If a deal isn’t Will private companies that provide services 5 June. The outcome will reached, the NHS to the public sector be eligible for funding to be known shortly aft er. Pay Review Body (NHSPRB) will make their implement the deal? Discussions are ongoing recommendations to the health secretary, Th e chancellor was explicit that additional in Wales, Scotland and who will decide the pay award for 2018-19. funding, above that already factored into the Northern Ireland, but Th ere are no guarantees on what this amount 2015 spending round, was tied to extensive members will be kept would be, but it is likely to reforms to the Agenda informed and will be be lower than the amount in PARTIES WILL BE for Change contract to consulted. Unite members the deal. help boost productivity. in these countries should ABLE TO GO TO Annex 1 of the NHS terms and contact their local branch What happens if infl ation THE NHSPRB WITH conditions of service handbook or representative to ensure they have shared their rises in the latter part of the CONCERNS ABOUT includes those organisations three-year deal? currently covered by personal email address Infl ation is forecast to keep HOW THE DEAL Agenda for Change. Th ere with Unite, as they will falling over the next couple PANS OUT is ongoing consideration as receive a country-specific of years, but we all know to how this applies for those email from the union. that these are very uncertain non-NHS organisations, For more information, economic times, not least because the effects such as social enterprises, that employ staff visit the joint union website of Brexit are not yet known. under the Agenda for Change contract. nhspay.org where you Th e trade unions insisted on a clause in Further information about eligible non-NHS will find more frequently the draft agreement confi rming that the employers will be included in NHS Employers’ asked questions and a pay NHSPRB will monitor implementation of the frequently asked questions. calculator to show what agreement, and that parties will be able to go the deal would mean for to the NHSPRB with concerns about how the Will I have to give up a day’s holiday? you. Also useful is the deal pans out. Th is means that if the economic No. All annual leave entitlements will remain NHS Employers site at bit.ly/NHS_framework SAM KERR situation changes signifi cantly, we will be as they are.
21 COMMUNITY PRACTITIONER | MAY 2018
21 Rights At Work.indd 21 26/04/2018 17:03 #CPHVA18 ANNUAL PROFESSIONAL CONFERENCE
BOOK NOW cphvaconference.co.uk
Unite-CPHVA Annual Professional Conference; Learn from the Past: Your Role, Your Voice, Your Future...
The 1918 general election and the suff ragette movement In the words of Lucy Stone, ‘now all we need is to continue paved the way for women’s rights as we know them. Although to speak the truth fearlessly’, so at this year’s conference we the past is to be learned from not lived in; some 100 years hope you’ll be infl uenced by our panel of expert speakers and on we would like to take this opportunity to celebrate the help lay the foundations for the next 100 years... empowerment and legacy this left behind. The Unite-CPHVA Annual Professional Conference and Exhibition will take place on 17-18 October 2018, at Bournemouth International Centre.
Whether you are a health visitor, a community nursery nurse, The two-day conference will boast plenary sessions community practitioner or school nurse, educationalist, of focused updates on key changes and policies aff ecting researcher or student there is something of interest for community practice in the UK, and dedicated break-out everyone on the programme. sessions allowing you to tailor a programme that meets your individual interests and learning requirements.
p22-23.CPMAY2018.indd 22 26/04/2018 17:13 Note: prices exclude VAT. Tickets include a buff et lunch with hot and cold refreshments. RATES TWO DAY TICKET ONE DAY TICKET
Early Bird rate: £123 Early Bird rate: £80 CNN/STUDENT/SCHOOL NURSE Normal rate: £144 Normal rate: £94 Early Bird rate: £205 Early Bird rate: £136 UNITE-CPHVA MEMBER Normal rate: £244 Normal rate: £159 Early Bird rate: £262 Early Bird rate: £160 NON-MEMBER RATE Normal rate: £314 Normal rate: £189
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p22-23.CPMAY2018.indd 23 26/04/2018 17:13 PRACTICE
pilepsy has been prominent in the press recently – on E issues including the use of cannabis oil to help seizures, and new regulatory measures on anti-epileptic drug (AED) sodium valproate for women and girls of childbearing age (see panel Drug rules changed for women opposite). Despite being a common neurological condition - around 600,000 people in the UK live with epilepsy (Epilepsy Action, 2018) – the causes are not entirely clear, diagnosis is not simple, and it can affect people in different ways. Th e main symptom of epilepsy however is a seizure (or ‘attack’), which is triggered when a sudden, intense burst of electricity overloads and disrupts communication between the billions of cells that make up the brain. Seizures come in many different forms, depending on the part of the brain affected and the intensity of the disruption, and the physical A CEREBRAL results can also vary. Some people will remain awake and have a strange feeling that they ‘switched off’ for a few seconds, while others will lose consciousness, become stiff, and then MATTER shake and jerk for several minutes. While epilepsy is a common condition, its WHO DOES EPILEPSY AFFECT? symptoms need careful consideration. What A seizure can happen to anybody exactly do you need to know and how can at any time, but it is not usually
described as epilepsy until a person you help? Journalist John Windell reports. LIBRARY SCIENCE PHOTO
24 COMMUNITY PRACTITIONER | MAY 2018
22-24 a i il s .indd 24 27/04/2018 12: 2 PRACTICE
has repeated episodes. Even then, a formal diagnosis is DRUG RULES the psychoactive effects of cannabis, not a simple matter, as Professor Hannah Cock, consultant CHANGED could cut the frequency of seizures neurologist at St George’s, University of London, and FOR WOMEN by 50% or more. A GP in Northern clinical adviser for Epilepsy Action, explains. ‘A diagnosis Ireland prescribed cannabis oil for a is determined by the history and witness accounts of Sodium valproate has boy with epilepsy who has up to 100 the episodes,’ she says. ‘Th at is quite a diffi cult thing been used to control seizures a day (Revesz, 2017), but the to get right, because a lot of other conditions can easily epilepsy since the 1970s. UK government has said it will not be mistaken for epilepsy [such as narcolepsy and heart Doctors have always license the drug (Kennedy, 2018). disorders]. So the UK guidelines stipulate that a diagnosis known it presents a risk Treating epilepsy is about more should be made only by a consultant who has specifi c to unborn children, but in than just controlling seizures, as the training and expertise in epilepsy.’ April the MHRA changed condition can also have a big impact Once epilepsy is confi rmed or strongly suspected, regulations on the drug on the quality of people’s lives. an EEG (electroencephalogram) test or MRI scan often for women of childbearing Nicola Swanborough at the Epilepsy follow. ‘Th ese in themselves are not diagnostic,’ says age (see bit.ly/SV_new_ Society explains: ‘While the medicine Professor Cock. ‘For example, some patients with epilepsy rules for full guidance). can control the seizures, the patient will have an entirely normal brain scan. Th ese tests can Nicola Swanborough might be having memory issues provide additional evidence, but mainly they are used to at the Epilepsy Society or sleep problems, and could be determine the type of epilepsy, the possible cause and the explains: ‘These new suffering anxiety. Th e medication can risk of recurrent seizures.’ mandatory measures also have side effects, such as mood It’s unclear why certain people develop epilepsy, but state that no girl or swings. All this can compromise it mostly affects the woman of childbearing people’s ability to work and socialise, under-20s and the over- ‘EPILEPSY IS potential should be and can undermine their confi dence. 65s. In children it can prescribed sodium My message to community appear for no obvious THE ONLY valproate for their practitioners is that one key thing reason, though it may NEUROLOGICAL epilepsy, unless no you can do is dig around a bit in a be hereditary, or it can CONDITION WITH other treatment is short consultation, look for those be triggered by a head effective. Under these issues and help to address them.’ injury or brain infection, A SIGNIFICANT circumstances, sodium So that means having awareness while in older people it RELATIONSHIP valproate should only be of such issues, and pointing clients has been linked to stroke prescribed as part of a to services where appropriate. And and dementia. In some BETWEEN pregnancy prevention of course checking female clients cases, it goes away as it DEPRIVATION programme, and all are aware of the new guidelines on appeared, without any AND MORTALITY’ women and girls on the sodium valproate. clear explanation. drug should be reviewed at least annually. WIDER ISSUES THE SOLUTIONS ‘However, it is important Something else to be aware of is When it comes to treating the condition, consultants have to stress that no girl or SUDEP – sudden unexpected death a wide range of AEDs to choose from. ‘We have around woman who is taking from epilepsy. According to the 25 of them in the UK,’ says Professor Cock. ‘Which one sodium valproate Epilepsy Society (2015), around we choose will depend on the type of epilepsy, the age of should stop without first 600 people die as a result of SUDEP the patient and other factors, including co-morbidities consulting their doctor.’ each year, though in many cases it such as depression, anxiety, or migraine. Because we Up to four in 10 babies is avoidable. ‘It can be people who have so many drugs, and because the treatment is highly exposed to the drug are are having clusters of seizures or individualised, the guidance says only specialists should at risk of developmental make those decisions.’ disorders, and around one In terms of dosage, the consultant’s basic principle is to in 10 are at risk of birth aim for the lowest dose of the fewest drugs that work. ‘We defects. Developmental normally try a relatively low dose of any given drug and problems include late then we see what happens,’ says Professor Cock. ‘If the walking and talking, seizures stop on that drug, you don’t go any higher. If the poor speech and patient has another seizure, you put it up a bit. So there is language skills and lower DID YOU KNOW? always a bit of trial and error.’ intelligence. Defects Seizures come in 40 Another treatment gaining some traction is cannabis include spina bifida and different types – people oil. A recent study in the Journal of Neurology, Neurosurgery malformations of the may experience more and Psychiatry (Stockings et al, 2018) showed that limbs, heart, kidney and than one. cannabis oil containing cannabidiol, which does not cause sexual organs.
25 COMMUNITY PRACTITIONER | MAY 2018
22-24 a i il s .indd 2 27/04/2018 12: 2 PRACTICE
perhaps not adhering to their EPILEPSY: TAKE ACTION ON SEIZURES medication,’ says Nicola, ‘or THE FACTS Commonly during a seizure, people lose those who are not taking care of AND FIGURES consciousness and begin to jerk or convulse. themselves, not eating properly, They may turn slightly blue as a result of drinking too much. Th ey are all at uneven breathing. These seizures normally a higher risk.’ last a few minutes but can go on longer. The A recent report from Public first aid steps for them can be remembered Health England (2018) showed with the ACTION mnemonic: that the number of deaths Assess the situation – are they in danger related to epilepsy among people of injury? Remove any nearby objects that aged over 20 in England has risen 5 out could cause harm. from just under 2000 a year in Cushion their head (for example, with a 2001 to more than 3000 in 2014. jumper) to protect it. It also showed that the rate of of 100 deaths in the most deprived people will have a seizure at Time: check the time – if the seizure lasts areas are almost three times some point – four will go on longer than five minutes, call an ambulance. the rate in the least deprived to develop epilepsy, though Identity: look for a medical bracelet or ID areas. In response, Epilepsy not all will have it for life card – it may give information about their Action’s chief executive Philip Around seizures and what to do. Lee said: ‘Epilepsy is the only Over: once the seizure is over, put them on neurological condition with a their side in the recovery position. Stay with signifi cant relationship between 87 them and reassure them as they come round. deprivation and mortality. It’s hard not to conclude that Never restrain the person, put something in of people are diagnosed the lack of priority given to with epilepsy every day – their mouth or try to give them food or drink. epilepsy within the healthcare it can affect anybody system has directly contributed If any of the following apply, call to the increase in premature an ambulance: mortality rates.’ You know it is a person’s first seizure. It seems that attitudes towards Around The seizure lasts for more than epilepsy may still have some five minutes. way to go. Nicola Swanborough 600,000 One seizure appears to follow another agrees that treatment can be people in the UK have the condition – about without the person gaining consciousness a postcode lottery. ‘It comes one in every 103 people in between. down to inequality of services,’ she says. ‘For example, some The person is injured. areas won’t commission the new You believe the person needs urgent medicines because they are too medical att ention. expensive. Overall, we would Epilepsy Action, 2018 like to see a much more joined- Flashing lights up approach.’ affect only 3% RESOURCES of people with epilespy The Epilepsy Society provides a wealth of background information and advice about the condition. Its helpline is also open to practitioners epilepsysociety.org.uk / 01494 601 400 of people with % epilepsy could Epilepsy Action also offers lots of resources, support and a helpline 70 be seizure free epilepsy.org.uk / 0808 800 5050 through better Epilepsy Research funds independent research into the condition treatment (it’s epilepsyresearch.org.uk currently 52%) Epilepsy Action, 2018; Epilepsy Society, 2016 NICE offers guidance and pathways on epilepsy bit.ly/NICE_epilepsy For full NHS Choices takes an overview of the condition and treatment references, visit nhs.uk/conditions/epilepsy bit.ly/CP_P_features
26 COMMUNITY PRACTITIONER | MAY 2018
22-24 Practice Epilepsy.indd 26 26/04/2018 18:18 IN TY PRA SI C PRACTICE R T I E C V I E
D
A FOCUS ON:
Continuing our series on how religion and culture can impact on practice, journalist Alia Waheed looks at Islam.
ne of the fastest growing religions in the UK, Islam is also one of the most misunderstood. O Th e community has increasingly found itself under deeper scrutiny, and some clients may feel a barrier between themselves and access to healthcare as a result. However, an understanding of the basic principles of the Islamic faith can help build an understanding between practitioners and clients to ensure best practice. Th e Muslim community encompasses a wide range of ethnicities and cultures. Hence the cultural traditions of Muslims of African origin will be very different to a Pakistani Muslim which in turn will be different from the experiences and attitudes of British Muslims. Also, various levels of observance exist among Muslims. However, what unites these diverse
cultures are fi ve core principles, known as ISTOCK
27 COMMUNITY PRACTITIONER | MAY 2018
27-29 Islam.indd 27 26/04/2018 17:21 PRACTICE
the fi ve pillars of Islam which are central to every Muslim’s beliefs. Th ese consist of Shahadah – the sincere declaration of faith, Salat – the ritual of praying fi ve times a day, Zakat – giving money DAILY PRAYERS to take medication at MUSLIM regular intervals. to charity, Sawm – fasting during (SALAT) FESTIVAL However, for people Ramadan, and Hajj – a once in a For many Muslims, their CALENDER who have been used to day is structured around 2018 lifetime pilgrimage. fasting every year (oft en the ritual of the five daily Muslim festivals Th e word Islam means submission you will come across prayers which take place follow the lunar and obedience to Allah’s will. Th e clients, particularly the at designated times calendar, so dates holy book of Islam is called the Quran. elderly, for whom fasting throughout the day. vary each year. While health is considered a gift from has been a part of their Many Muslims, The main ones are: lives for decades), the Allah, health problems are perceived as especially the elderly, idea of not being able to RAMADAN Allah’s will, so Muslims are encouraged can become anxious take part can be almost (15 May to 14 June) to accept their condition with dignity. about visits by healthcare traumatic to accept, and takes place in the However, Muslims are encouraged to professionals clashing with some people may be ninth month of be proactive in seeking help, rather prayer times, and prefer stubborn about giving up the Islamic year not to have appointments than waiting for divine intervention. So the ritual and may need when the Quran on Fridays when they taking care of their health is considered help understanding the was revealed wish to devote themselves their duty. Awareness of the Muslim reasons why. to the Prophet to worship. faith can enable practitioners to Muhammed by Allah. encourage better healthcare choices. HOW DOES THIS HOW DOES THIS ‘We all need to be respectful of our AFFECT YOU? AFFECT YOU? EID UL-FITR client’s beliefs and practices and where If you have a client who is (14 June) Where possible, be possible to try and accommodate these adamant about fasting, marks the end of mindful of prayer rituals when trying to personalise care,’ says you may need to help Ramadan and is and timings when making Professor Aziz Sheikh, author of Caring them look at ways of the holiest day of appointments. Muslim helping them manage the Islamic year. for Muslim patients. ‘It is important to clients will be particularly their condition while People celebrate try and share insights about beliefs, reluctant to book fasting. Diabetes UK have and give thanks to cultures and practices that UK health appointments on Fridays a guide to fasting with Allah. Most people professionals might be unfamiliar with.’ or on the festivals of Eid diabetes for instance. take the day off ul-Fitr and ul-Adha. If this is not possible, work or school and THE 5 PILLARS Shahadah intervention from the visit the mosque. They distribute OF ISLAM The sincere RAMADAN local Imam to explain sweets and food declaration With Ramadan around the Islamic perspective to neighbours. of faith the corner, many Muslim – placing emphasis on Salat clients will be focused taking care of your health EID UL-ADHA The ritual on ggett inggp preparedp – may help. (21 August) of praying for a month of sspiritualpiritual remembers the five times devotion,devotion, iincludingncluding fastfastinging Prophet Ibrahim’s a day (no food or watwater)er) from willingness to Zakat dadawnwn uuntilntil dusdusk.k. sacrifice his son to Giving WiWithth the dadailyily fafastssts prove devotion to money to lastlastinging almost 19 hours Allah (Allah gave charity ththisis yyear,ear, itit can be a him a sheep to Hajj challenchallengingging time. PrePregnantgnant sacrifice instead). wwomenomen are exemexemptpt fromfrom Once in People pay for fastinfastingg ((itit is considered unun-- a lifetime an animal to be IIslamicslamic as it cacann be hharmfularmful pilgrimage sacrificed and to the unborn childchild),), as meat is distributed Sawm are pepeopleople wwithith health to those in need, Fasting coconditionsnditions oorr whwhoo hhaveave friends and during neighbours. Most Ramadan take the day off work or school and visit the mosque.
28 COMMUNITY PRACTITIONER | MAY 2018
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MODESTY with this. It’s very important that where possible, a practitioner of the same gender A key barrier to seeking medical support, is available and examinations be carried out particularly among women are issues around with sensitivity and discretion. Clients should modesty and dress. Some women may be made aware of how vital gynaecological neglect their maternity and gynaecological health is,is, especiallyespecially smearsm tests. health as a result. For example,ple, manmanyy Muslim women avoid havingg a smear test, and there’s less understandingtanding CONTRACEPTIONCONTRACEPTIO of its purpose among Asian women The MMuslimuslim fafaithith strstronglyo advocates (Jo’s Cervical Cancer Trust, 2016).2016). family,family, aandnd chchildrenildre are considered a gift A women who wears a hijabab wwillill from AAllah.llah. CContraceptionont is accepted be uncomfortable being examinedamined inin Islam, as iiss hhaving a healthy sex DIET by a practitioner of the oppositeposite llife,ife, but iinn ttheh context of marriage ‘Halal’ means permissible and while sex, particularly if it involvess between a hhusband and wife. it applies to all aspects of Muslim being partially undressed. However,However, ddueu to issues around life, it’s most commonly associated Muslim women are also modestymodesty andan sexual purity before with food. Muslims can only eat halal the least likely to take part marriage,marriage, mmany people, especially meat – which is meat that’s been in sports and activity which women,women, mamayy not have access to slaughtered according to Islamic can impact wellbeing (Sportt ccontraceptiveontraceptiv information which ritual. If halal meat is not available, England, 2017). can lead to healthhe problems. Muslims will opt for vegetarian or fish. Products derived from pigs such HOW DOES THIS HOHOWW DODOESES TTHIS AFFECT YOU? as bacon, or by-products such as AFFECT YOU? Ensure clientsclients are fully informed gelatine, are forbidden, as is alcohol. It’s best not to shake hands withwith about contraceptioncontra options. WomenWomen inin pparticular may need HOW DOES THIS AFFECT YOU? someone of the opposite sex,ex, iinn case a client is uncomfortableble additionaladditional information and Oft en Muslim clients will refuse reassurancereassuran on confidentiality. medication containing gelatine or other non-halal ingredients. This was The elderly are expected to be taken care of by younger relatives: parents live the case with many Muslim parents with sons and their wives as the main caregivers (culturally, the main share and the flu vaccination for children of responsibility falls on the daughter-in-law). There can be a stigma towards (Blackstone, 2014). Alternatives having a carer, as it’s seen as a source of shame. Some clients may be in denial should be sourced where possible, but about the need for a carer; if you feel one is needed, it’s worth suggesting. if a condition is life-threatening, such considerations can be overridden. PILGRIMAGES HAJJ AND UMRAH (to Mecca, Saudi Arabia) RESOURCES CIRCUMCISION Hajj can only be performed in the 12th month of Caring for Muslim the Islamic year and is compulsory for every adult In Islam, circumcision is compulsory patients by Professor once in their lifetime. Umrah is non-mandatory Aziz Sheikh and for boys mainly for hygiene reasons. and can take place at any time. While there’s no set age, people are Abdul Rashid Gatrad oft en guided by cultural preferences. HOW DOES THIS AFFECT YOU? (Routledge, 2002) on Generally, the earlier the bett er all aspects of care. The pilgrimage is a very important event so a seems to be the prevalent att itude. Muslim Women’s Circumcision, of course, is a very Muslim client is unlikely to change their plans unless it is a matt er of urgency. Where possible, Network UK is a useful different practice from FGM, which resource for issues is forbidden in Islam, and illegal in a client should be given support to manage their specific to Muslim the UK, but still happens in some condition while on pilgrimage. Oft en people will women mwnuk.co.uk communities abroad. go with a tour group; liaising with the operator so they’re aware of the client’s needs is a good idea. Muslim Council of HOW DOES THIS AFFECT YOU? Britain is a national New mums, especially when it is body encompassing their first child, will be anxious mosques, schools, and about the their son’s circumcision. charities mcb.org.uk So a non-judgemental approach is always appreciated. Having a list of recommended doctors who can For full references, see carry out the procedure safely and bit.ly/CP_P_features
ISTOCK / SHUTTERSTOCK ISTOCK hygienically is considered helpful.
29 COMMUNITYCOMMUNITY PRACTITIONERPRACTITIONER || APRILMAY 20182018
27-29 Islam.indd 29 26/04/2018 17:21 PRACTICE
Retired health visitor Sue Moos looks at assessing eligibility for older people’s NHS-funded care, new developments to prevent postcode lott eries and the implications for health professionals. CONTINUING HEALTHCARE FOR THE ELDERLY
ealth visiting has recently undergone a shift in emphasis towards the increasing number of older people living with one or more long-term H health conditions. Health visitor teams for older people support frail, elderly people in living well and independently and reduce avoidable hospital admissions. Some older people have signifi cant healthcare needs that require considerable care and support or highly specialised nursing. In England, NHS continuing healthcare (CHC) is a package of ongoing care for individuals aged 18 or over, arranged and funded by the NHS for individuals whose needs exceed what can legally be provided by local authorities (LAs). Th e National framework for NHS continuing healthcare and NHS-funded nursing care (Department of Health (DH), 2012) sets out the principles and processes to establish eligibility for CHC and care planning. Th e importance of CHC cannot be overstated – those not eligible for CHC may have to pay for all or some of their social care costs, although they may still be eligible for
NHS-funded nursing care. GETTY
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As health visitors for older people are likely relates to delays in the process. Complaints to have conversations with their clients about highlighted by the National Audit Offi ce (NAO) CHC and be part of the assessment process to revealed the scale of the problem in 2015-16, determine eligibility, it is imperative they are up when around a third of those assessed in England to date with the framework and its processes. for CHC (24,901 people) waited longer than 28 Th ey also need to understand the potential days for a decision on their eligibility (NAO, 2017). pitfalls, be aware of changes and know how to DECISION An additional delay not covered by the NAO’s best support their clients. investigation is the length of time between SUPPORT requesting an assessment and having the checklist AN OVERVIEW OF CHC TOOL: CARE completed – when the clock starts ticking – which Legal duties and responsibilities for NHS CHC lie DOMAINS can be a source of considerable stress. with clinical commissioning groups (CCGs) and Th e NAO (2017) also found a ‘signifi cant LAs. Mandatory national tools exist to support variation between CCGs in both the number decision-making – the CHC checklist, decision and proportion of people assessed as eligible support tool (DST) and fast-track pathway Behaviour for CHC’. In response, the House of Commons tool. Th e key steps are, fi rst, to establish if an Public Accounts Committee report published individual has a ‘primary health need’; second, its recommendations to the Department of to arrange an appropriate care package. Cognition Health and NHS England, including improving Th e concept of ‘primary health need’ is used to awareness of CHC and a national oversight assess eligibility for CHC funding. Establishing a process (UK Parliament, 2018a) and, following the primary health need is complicated because there Psychological and government’s response, a series of improvements is no legal defi nition, although the Coughlan case emotional needs is expected during 2018 (UK Parliament, 2018b). of 1999 set a precedent for what the NHS should pay for, and what exceeds LA responsibilities in IMPLICATIONS FOR PRACTICE its provision of nursing (DH, 2012). Communication Health visitors need to have up-to-date Th e process starts with the checklist – a trained information about funded nursing care and CHC assessor uses this initial screening tool to identify and be a source of information, signposting and those who need referral for full assessment. A Mobility support throughout this complex, potentially more in-depth DST assessment, carried out by a lengthy and stressful process. multidisciplinary team (MDT), considers needs Two key points vital in understanding under 11 specifi c domains and an additional Nutrition eligibility for CHC funding are that decisions domain to capture other health needs not already on eligibility should not be based on a person’s covered (see box 1). Th e DST assesses factors diagnosis, and that needs should be assessed in addition to the ‘nature’ of the health need: Continence as if they are unmanaged, that is focusing on ‘intensity’, ‘complexity’ and ‘unpredictability’ underlying needs. Th e National framework says: (together known as NICU) to determine certain ‘Th e decision-making rationale should not characteristics of need, their impact on required Skin, including marginalise a need just because it is successfully care and whether the ‘quantity’ or ‘quality’ tissue viability managed: well-managed needs are still needs. of that care exceeds the limits of the LA’s Only where the successful management of a responsibility. Following the DST MDT meeting, healthcare need has permanently reduced or a recommendation is made to the CCG CHC Breathing removed an ongoing need, such that the active panel. For individuals approaching the end of life, management of this need is reduced or no longer the fast-track pathway tool ensures a speedier required, will this have a bearing on NHS CHC route to assessing eligibility and accessing an Drug therapies eligibility’ (DH, 2012). appropriate care package. and medication: Evidence from health-visiting records can symptom control TIMEFRAMES AND DELAYS Th e checklist should be completed within 14 days ‘THE DECISION-MAKING of a request and a decision should be provided Altered states RATIONALE SHOULD NOT by the CCG within 28 days. Exceptions to this of consciousness MARGINALISE A NEED JUST include, for example, where an individual is in hospital, when the checklist should only be BECAUSE IT IS SUCCESSFULLY completed following the acute care episode when Other significant MANAGED: WELL-MANAGED the discharge needs are clear. care needs Despite the timescales set out in the National NEEDS ARE STILL NEEDS’ framework, one of the most frequent complaints Department of Health, 2012
31 COMMUNITY PRACTITIONER | MAY 2018
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and should be considered as part of battle with the NHS over her parents’ care – and the assessment and assessors may Beacon, a social enterprise offering free expert advice ask for copies. When it comes to the and affordable representation. Age UK and the Resources for DST assessment, health visitors are Alzheimer’s Society also provide useful leafl ets and individuals and ideally placed to be an advocate for advice and Beacon, commissioned by NHS England, individuals – the National framework provides a free telephone advice service (see box 2). their families requires that the DST MDT is made Health visitors may also consider training in CHC as up of professionals who have direct part of their continuing professional development Information for knowledge of the individual and (CPD) (see Resources for health visitors, below). NHS users on their their needs. eligibility for CHC Health visitors should be alert CHANGES EXPECTED bit.ly/CHC_NHS to terminology correctly refl ecting A revised version of the National framework and its an individual’s needs as this will associated tools, which take effect on 1 October Specialist online guide the MDT’s decision when they 2018, are already available online (see box 3). Further information resource assess NICU. For example, the term developments to watch out for by the end of 2018 about NHS CHC funding ‘generally’ might lead are actions by CCGs to reduce delays in England for individuals the MDT to think a in accessing care packages, plans to and their families need is not suffi ciently HVs NEED TO raise awareness about CHC among caretobedifferent.co.uk/ serious when in fact UNDERSTAND individuals, health and social care about the person is wholly professions, and changes to ensure THE POTENTIAL dependent on others consistency within and across CCGs. Specialist advisers to meet their need. PITFALLS, BE Th is challenging programme must Beacon offer a free Similarly, terms such AWARE OF be delivered while achieving £855m navigational toolkit and as ‘independent’ and effi ciency savings in 2020-21 (UK up to 90 minutes of free ‘needs assistance’ CHANGES AND Parliament, 2018b). advice with a trained implies they are KNOW HOW TO Th e key points for health visitors NHS CHC adviser (0345 548 0300) able to manage, BEST SUPPORT supporting older people going through just needing a little the CHC eligibility assessments beaconchc.co.uk help, when in reality THEIR CLIENTS are to be familiar with the process, they may be entirely keep up to date with changes and Tips on applying dependent on others. know how the local CCG manages for CHC and a Care To Be Different, a assessments. Training should be useful factsheet campaign group that advises on care made part of ongoing CPD activities. Ensure records bit.ly/CHC_AgeUK fees, says it can have a profoundly refl ect the requirements of the DST so that the older negative effect on the outcome person’s needs – and the recording of their intensity, Advice based on of the assessment and is ‘hugely complexity and unpredictability – are presented in the experience of disrespectful towards a person such a way that helps assessors and the DST MDT to members of the needing care when assessors try to fully understand the impact on the individual and the Alzheimer’s Society NHS brush the person’s serious needs level and type of care the person needs. Continuing Healthcare under a carpet of positive language’ Volunteer Group who (Care To Be Different, 2017). Sue Moos is a retired health visitor, midwife have been successful Knowledge about local CCG CHC and general nurse with over 30 years’ experience. gett ing CHC for people processes and performance will She maintains a keen interest in practice-related with dementia help health visitors in supporting issues for community practitioners. bit.ly/CHC_Alzheimer’s individuals and managing expectations. Additional useful local information can be gained from CCG Resources for health visitors Freedom of Information reports, available on CCG websites. An overview of NHS CHC england.nhs.uk/healthcare Specialist support organisations Online CHC e-learning tool for health professionals bit.ly/CHC_ELFH that health visitors can pass National framework for NHS CHC and NHS-funded nursing care bit.ly/CHC_NF information about on to clients include Care To Be Different – set up by Angela Sherman after going For full references, visit bit.ly/CP_P_features through a long and gruelling CHC
32 COMMUNITY PRACTITIONER | MAY 2018
0- 2 ld l .indd 2 27/04/2018 12: 24 HOURS WITH ALIMATU DIMONEKENE
Alimatu is lead advocate for ProjectACEi – a community group who advocate, educate and @ProjectACEi engage communities to end FGM.
MY DAY BEGINS… and engaging communities making a call to arrange a GP most of my work is done on a around 6.30am with a fi ve- and health professionals in appointment. Although I see shoestring budget. I recently minute meditation and helping to end FGM. As an women at the centre, I mostly had a call from a young woman stretching to gather my thoughts anti-FGM advocate I often get see them in their homes. I refer worried that if she returned to for the day ahead. Working on referrals from practitioners and women with severe needs on to her home country she might be FGM is tough, and it’s important professionals – mainly empowerment sessions subjected to FGM. Given this to look after myself. By 6.40am from local hospitals for further support. risk, I made a referral to the local I’m checking emails for urgent and agencies authority adult safeguarding messages. I also check WhatsApp requesting support MY WORK IS team to assist her with obtaining messages from two community for women. EMBEDDED… an FGM order from the family women’s group forums I But being a within the courts. Th is was the most manage. Usually I’ll have urgent community group community. I remedial action I could offer: messages or safeguarding and not a statutory spend most time with more resources, I could concerns raised to respond to. body, I can only see with individual have done so much more. women over 18 who members. I also often I LEAVE HOME AT… have undergone FGM. have outreach community THE BEST PART OF 8am for a 45-minute walk to my engagements such as hosting MY JOB… local drop-in centre. A free space MOST OF MY community workshops and is seeing the smile on women’s is offered to me by the council to APPOINTMENTS ARE… training. Here I discuss the risks faces when they realise that see women affected by FGM. a combination of an initial associated with FGM, and the someone is listening to them My fi rst appointment at the face-to-face appointment importance of the communities and not judging them. centre is around 9.30am. to identify potential risk, a in helping to prevent women and welfare needs assessment girls from being subjected to it. POST-WORK… I AM RESPONSIBLE and casework to help I often attend meetings in central FOR… women in accessing AS A SURVIVOR OF FGM… London which takes up most supporting women further support I know how diffi cult it can be of my evenings. I am in bed by who have been services. Th is ranges for women with no support 11pm, often exhausted, knowing affected by FGM, as from simply offering in dealing with their trauma. that with more funding , I could
IVAN GONZALEZ / ISTOCK IVAN well as educating a support letter to But given the lack of funding, do so much more.
33 COMMUNITY PRACTITIONER | MAY 2018
24 i ....indd 27/04/2018 12: MumMum
I was born inin the wrong body – God mademade a mistake 14:2714:27
Don’t worry, it’st’s just a phase... you’lll grow out of it 14:36
34 COMMUNITY PRACTITIONER | MAY 2018
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The mental and physical health of trans young people is suffering, to the point they’re even accessing healthcare less oft en, and they continue to face considerable stigma. What can you do to help ensure they’re as healthy and happy as they should be? Journalist IS Phil Harris reports. ANYONE LISTENING?
he was about nine when I caught When Sarah complained, she was accused of child abuse for her in the bath with a broken razor, making Olivia feel confused about her gender identity. about to attempt some self-surgery ‘Th e GP offered to sign Olivia off school, but she said on her genitals.’ she didn’t want the bullies to win. Th e school provided For Sarah, a mother of four, no support in tackling the bullies – I was told things this discovery was a chilling new like: “Children need to learn that their decisions have development in the already-traumatic consequences.” One staff member would call Olivia “it”. life of her second-eldest child. Th is was how they treated an innocent and frightened child.’ ‘SBorn a boy and christened Oliver, her child had from an Next, Olivia developed anorexia and began to lose early age questioned why she was a boy, and from the age of weight alarmingly. six had wanted to dress as a girl and be called Olivia. Sarah says: ‘As a young child she would say “God has TRAUMA FOR TRANS PEOPLE made a mistake with me and put me in the wrong body.”’ A recent US study (Rider et al, 2018) revealed that just 38% After the bath incident, Sarah sought an emergency of school-age trans young people describe their health as appointment with a GP. ‘He was brilliant and very ‘very good or excellent’, compared with 67% of the non- supportive, even though he admitted he had no experience trans (cisgender) students. in this area,’ she says. About 60% of the trans respondents had long-term Seeking the help of the GP turned out to be a wise move. mental health problems, and around 25% had physical Olivia’s experience at her school had been bleak. According disabilities or long-term health problems (such as asthma to Sarah, staff turned a blind eye to the constant bullying or epilepsy). In comparison, 17% of cisgender teens had and violent attacks Olivia received daily from other pupils. psychological problems and 15% had physical health issues.
35 COMMUNITY PRACTITIONER | MAY 2018
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THE TRUTH ‘Trans’ is considered more ABOUT TRANS respectfultful and inclusive than ‘transgender’ or ‘transsexual’
the impact of mental health over Trans can refer to anyone the impact on their physical health, and will sometimes whose gender identity does compromise one over the other. not completely matchch the sex He says: ‘Gender dysphoria they were assigned at birthh [distress caused by a mismatch between a person’s biological 38% sex and their gender identity] of trans school-age is a complex issue, and any health children said their Th e situation is similar in the UK, appointments relating to a health professional having to health was ‘very good or where an alarming 84% of trans examine parts of their bodies that they don't want anyone excellent’, compared with young people in the UK have self- to see, because of gender dysphoria, is a huge barrier to harmed and almost half (45%) have accessing healthcare.’ attempted to take their own life. In fact, Rider et al (2018) also found that while more Nearly two in three trans pupils are than half of young people had preventative health and % bullied at school, while one in 10 dental check-ups in the past year, this was less likely to 67 of non-trans children have received death threats. One in happen for trans teens. three trans pupils say they are not It’s hardly surprising that trans young people like Olivia Rider et al, 2018 able to be known by their preferred are more likely than their cisgender counterparts to have name at school, while three in fi ve poor mental and physical health. (58%) are not allowed to use the toilets they feel comfortable in STOPPING THE STIGMA (Stonewall, 2017). Sarah, Oliver and Olivia are not the real names of the While a growing number of schools people in the opening story, partly because there is still a are supporting their trans pupils, too great deal of stigma around trans issues. many are not equipped to do so. Th e Sadly, nor is their experience of school hostility survey found that more than two in unusual, says Susie Green, chief executive of the charity 1 in 3 fi ve trans pupils (44%) said that staff Mermaids (which supports gender-diverse children, trans pupils say they at their school are not familiar with young people and their families). are not known by their the term ‘trans’ and what it means. ‘Overall we fi nd that usually school staff and other preferred name at school Some even cited examples of school professionals just don’t know enough about the subject, staff making fun of trans people or what to do about it.’ (Stonewall, 2017). Stigma is an important factor in the way trans children Meanwhile, research shows that are treated by parents, professionals and wider society, trans people generally experience Susie explains, as many will try to discourage or deny Th e number of trans signifi cant inequalities in health, what is happening. people in the UK wellbeing and broader social and ‘A lot of the negative reactions are based around becoming visible is rising economic circumstances (PHE and fear of the unknown, such as what it will mean about PHE and RCN, 2015 RCN, 2015), despite legislation such work, relationships and what others think. But denying as the Equality Act 2010, which something that is inherently part of someone is not going makes it an offence to discriminate to make it go away. It will just make the young person feel against trans people. invalidated, isolated and alone.’ Matthew Waites, a UK trans youth Susie, whose own child questioned her gender at the worker and author of the book age of four, has received constant abuse and even death It’s been estimated that Supporting young transgender men: a threats over the work of the charity, and calls transphobia one or two children in a guide for professionals, thinks that the ‘last bastion’ of discrimination. class of 35 pupils are trans trans young people will try to balance ‘Most of society now rightly considers it unacceptable Kuyper and Wijsen, 2014
36 COMMUNITY PRACTITIONER | MAY 2018
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to discriminate against people based on the colour of their appointment is now 14 months, placed to infl uence school thinking skin or their sexual preference. But many seem to think as demand has been increasing generally about discrimination and it’s still okay to be openly anti-trans, even though it’s dramatically. Professionals should creating a culture of knowledge and outlawed in the Equality Act.’ judge the Gillick competence of acceptance, Susie adds. Th e issue However, there are signs that things may be changing, the young person before referring, may become more acute for young with trans issues now having a higher prominence than and they will take responsibility for people when they hit puberty and ever before, and there is an international ‘trans day of referring, even without parental their bodies begin to change. visibility’ on 31 March each year. consent if necessary. School nurses Claire Elwell, who has over a Technology is also playing a large part in changing can also refer to GPs and CAMHS. decade’s experience as a school nurse attitudes, according to Bernard Reed, a trustee at the Th e pathway may lead to hormone in the north east of England, agrees Gender Identity Research and treatment and that school nurses are very well Education Society (GIRES). He says: ultimately situated to support young people ‘Young people are very media savvy ‘DENYING SOMETHING surgery, with gender identity issues, but says and fi nd it much easier to access THAT IS INHERENTLY PART although this is education and funding shortcomings information and speak to similar OF SOMEONE IS NOT not the case for often act to prevent better care. people. Trans young people are not as the majority for ‘School nurses are very open- isolated as they used to be.’ GOING TO MAKE IT GO GIDS referrals. minded and any training would AWAY. IT WILL JUST MAKE Susie be warmly received and added to YOUR ROLE THE YOUNG PERSON FEEL acknowledges the already wide knowledge-base Susie says there is much that that some adults they have. Trans and gender issues public health nurses can do to help INVALIDATED, ISOLATED are likely to are often areas that sow confusion children who have gender identity AND ALONE’ consider trans among professionals and the public, issues – and their families – and that in young people and better education could help to school nurses can play a particularly as a phase, and breach the gaps. important role. be tempted ‘But there are fewer school nurses ‘Young trans people may disclose to simply on the ground now, and that has an to staff at school. If this happens, it’s important to listen monitor it and wait for them to impact. Some drop-in services exist; to the young person and not try to persuade them to do grow out of it – generally termed however, these are time and venue- or be something else. Th ey shouldn’t be embarrassed or ‘watchful waiting’. limited sessions, so young people ashamed of how they are feeling. ‘Of course children should don’t have much opportunity to talk ‘School nurses can give support and guidance, and be allowed to experiment and to us about their issues.’ obviously won’t break any confi dences. Th ey may end explore,’ Susie says. ‘But if they are Claire points out that many up taking an advocacy role and help the young person to consistently saying that’s who they professionals seem to lack knowledge discuss the subject with others, such as family members. are, then this should be respected. on trans issues, and so it is likely that ‘It needs to be acknowledged that what the young Th ey have to go through so much to many teachers will struggle with person is thinking and feeling isn’t a choice, and they may become who they are, and it takes a the subject. have been struggling with it for years. If a school nurse lot of bravery and commitment.’ hears that disclosure then it is a big responsibility.’ School nurses are also well PRACTICAL STEPS School nurses can also refer young people to the While there may not yet be Gender Identity Development Service (GIDS) at quite the body of guidelines the Tavistock and Portman NHS Trust, which deserved on trans issues is specifi cally for children and young people In appointments, avoid for those looking after experiencing diffi culties with gender identity. words such ass ‘boys’, ‘girls’, young people, professional Th is national specialised service is the only guidance is out there – one of its kind in the UK, and will carry out ‘mother’, or ‘father’... many advice and guidance a full assessment – they also documents have been have a clinic in Leeds, and created by charities or satellite clinics. Often support groups, and some working alongside child ...Try usingusing gender-neutralgender-neutral have been produced by health and adolescent mental languageguage e.g. ‘parent’, ‘young organisations such as individual health services (CAMHS), NHS trusts (see Professional GIDS staff will help the people’ instead. Or be guided guidance, overleaf). young person to choose Matthew says there are many a path that best suits by terms that the trans young practical steps school nurses in them. Unfortunately the person prefers PHE & RCN, 2015 particular can take, both to support waiting time for a GIDS young people and promote inclusive
37 COMMUNITY PRACTITIONER | MAY 2018
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PROFESSIONAL Reassignment may include GUIDANCE hormonee treatment and/or surgery Free e-learning on caring for gender-variant to alter physical characterisristicstics young people bit.ly/Elearn_GIRES_trans environments. For PHE’s Preventing suicide example, they can Gender reassignment/confirmation/ among trans young people call ahead to other gives information on the law professional services affirming: the intentionntention to undergo, and effective communication that young people undergoing or having undergonendergone bit.ly/PHE_young_trans may need access to, such as gynaecology transition sociallyally The Trans Inclusion Schools or sexual Toolkit has practical advice health services. bit.ly/trans_schoolkit ‘Th at way, they can decide how a people feel safe in accessing services. young person wants to be addressed ‘Using gendered language that doesn’t quite fi t a Health factsheets when they get there and the young young person’s identity makes a very clear statement produced by the National person won’t have to explain that organisations may not be trans friendly. Th ings LGB&T Partnership themselves and their identity before like that may seem very minor, but it’s always bit.ly/trans_health they start to discuss the issue.’ noticed. It sends a clear message that organisations Professionals can also accompany aren’t educated and don’t understand trans issues. NHS guidance on young people to appointments where ‘If young people start to feel that impact, they are gender dysphoria appropriate, and this can encourage less likely to want to engage with services, less likely bit.ly/GD_NHS positive mental health and emotional to address health issues, and their mental health will
wellbeing, Matthew says. suffer as a consequence.’ GIRES Training for health ‘If professionals see things that On the other hand, if schools take a positive professionals and schools need addressing with regards to approach this can have a signifi cant impact. In the gires.org.uk services and the way they treat young case of Olivia, she eventually switched schools, and people because of their identity, it’s the experience could not have been more different. Mermaids UK A charity for always important to challenge this. ‘Th ey have been brilliant,’ her mother Sarah says. trans young people, from ‘Th is will demonstrate to young ‘With the school’s help, I offered to speak to the staff parents of trans children people that they can take control in and parents, and give them a chance to ask questions. mermaidsuk.org.uk a positive way. Being a role model I wanted to be completely transparent and honest. who challenges bad practice can ‘I explained Olivia’s experience and journey, and GIDS One-of-a-kind NHS give young people the confi dence to the fact that she wanted to live as a girl. Th e only centre offers guidance address health needs in the future, questions I got asked were about how I am coping for young people, parents because they'll have the tools to cope and what to do about play dates. Everyone has been and professionals if something does go wrong.’ incredible and embracing, and some even brought me gids.nhs.uk Matthew also thinks simple and in spare dresses. inexpensive steps at healthcare ‘Olivia now has a nice group of friends. Her eating Sandyford Integrated sexual, provider organisations, including problems have disappeared, and she goes to and from reproductive and emotional schools, can make a difference. ‘We school with a smile on her face. health service across all know that money is tight within ‘Before our experience, I used to think trans people Greater Glasgow and Clyde services, but things like putting up were damaged emotionally and possibly trying to bit.ly/sandyford_Scot posters that explicitly state you’re a change themselves to run away from problems. But trans-friendly organisation will go I’ve seen that it’s not like that. UK Trans Info Links to a long way to encouraging young ‘We just want acceptance, tolerance and guidelines and protocols people to open up. understanding, and for everyone to be comfortable in for healthcare professionals ‘Having gender-neutral spaces their own skin. Th at doesn’t seem too much to ask.’ from UK organisations such as toilets and changing facilities, uktrans.info as well as using gender-neutral language in policies and procedures For full references, see Via Twitt er: @Genderintell, that young people may access, will bit.ly/CP_features @AllAboutTrans, @TmsaUk go a long way to ensuring that young
38 COMMUNITY PRACTITIONER | MAY 2018
4- 8 a .indd 8 26/04/2018 18:2 GUIDELINES FOR AUTHORS What would you like to write for your journal? A short feature perhaps? Or maybe an opinion piece? Do you know how to go about it? Whatever content you would like to write, you can now find our full author guidelines online at communitypractitioner.co.uk/author-guidelines
AUTHORSHIP
REFEREES AND REVIEW COPYRIGHT
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39 GuidelinesforAuthors.indd 1 27/04/2018 12:33 FEATURES
PLANT-POWERED PARENTING Increasing numbers of parents are opting to bring up their children on a vegan diet. But is this advisable – or sustainable? Journalist Radhika Holmström asks a panel of specialists.
ver the past fi ve years, veganism has moved from the fringe to a mainstream lifestyle choice. In April this year, new research O suggested that around 3.5 million, or 7%, of the UK’s population now identifi es as vegan (Roberts, 2018). However, is this a diet nutritious enough for young children? One recent study suggests that proteins sourced from plants are far better for heart health than those derived from animals (Th arrey et al, 2018). Others argue that this is all very well for adults, but babies and young children have different nutritional needs and should not have a vegan diet enforced. We asked a variety of specialists, professionals and parents their views.
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THE PAEDIATRIC DIETITIAN Aisling Pigott , THE VEGAN ADVOCATE British Dietetic Association Heather Russell, dietitian, the Vegan Society A vegan diet can be contain less iron and they’re harder for appropriate for anyone the body to absorb. If you research and plan – parent or child – but it From a practitioner point of view, carefully, you can provide all needs to be well planned. the main thing is to ensure that the nutrients essential for A parent who’s read online children are getting calcium and iron, health and development in a that a vegan diet is supposed to be and that, as a child comes off milk, vegan diet for children. In my better for children, and just cuts out all know that there are no non-animal experience, vegan parents put a lot of dairy, is very different from someone sources of vitamin B12 – so that is one attention into thinking about diet and who has thought through their choices thing they will need in a supplement. health – it’s likely, too, that they’re quite and knows what essentials need to Some supplements often contain passionate about breastfeeding [because of be added. animal-based gelatin, so parents may the unavailability of dairy-free formula]. I’d ask a pregnant woman how need help fi nding alternatives. It’s certainly possible to plan nutritious she was thinking of feeding her Th ere’s so much information online meals very easily, and it doesn’t have to baby. Soya milk and the nutritional advice be expensive in terms of the nutrition isn’t recommended that is shared, without you’re getting for your money, especially before six months, any basis, is staggering. if you’re avoiding processed foods. so what are your As a practitioner, you’re It’s possible to introduce nutritious options? Th en, when often a worried mum’s fi rst foods without animal products. Soya it comes to weaning, main source of nutritional yogurts, chickpeas and so on are good young children of advice, so it’s important sources of iron – which weaning babies weaning age have to know a bit about it and need – especially if you increase the particularly high iron which organisations you uptake of iron with vitamin C. If you’re requirements. It’s might be able to turn to. concerned, it’s always a good idea to perfectly possible Most paediatric refer parents on for expert advice; but to meet those dietitians are keen to share do ask how they feel about it because, in requirements through and upskill our health- my experience, a lot of people are very a vegan diet, but you visiting colleagues, so it’s worried about seeing a dietitian because do have to be aware always worth contacting they’re concerned they may not get of it – make sure the your local paediatric advice in line with their needs. child is meeting the dietetic team if you need Realise that vegans avoid animal use as requirements, because to clarify any points much as possible. Part of our defi nition non-animal sources or advice. of veganism realises that it’s not always possible to avoid animal use in a non- vegan world – for example, you might RAISING VEGAN CHILDREN WITH CARE have no alternative to using a medicine that contains animal ingredients or has There’s broad agreement, even from many of those not in favour been tested on animals. And formula is of a vegan diet, that it can be workable for children. Last year, the a problem as even soya formula contains British Dietetic Association, working alongside the Vegan Society, vitamin D derived from animal fats. confirmed that a well-planned vegan diet can ‘support healthy However, vegans in the UK are protected living in people of all ages’. However, parents must still exercise under human rights and equality law care bringing up their children on a vegan diet: too, so there’s a duty to ensure they’re Supplementation of vitamin B12 is essential nott didiscriminatedscriiiminattedd agaagainst,g iinstt, iin ththe sasameme Children also need good levels of iron and calcium (which may wawayy tthathat peoppeoplele witwithh ototherher bbeliefseliefs mean supplementation) are protectedprotected.. Supplements should be vegan-friendly – for instance long-chain omega-3 fatt y acids are best in marine-derived form, which means an algae-based supplement is the only non-fish option Vegan children with multiple allergies or other dietary restrictions may need specialist att ention Parents focusing too much on removing or restricting foods,
ALAMY / GETTY / ISTOCK / SHUTTERSTOCK / SHUTTERSTOCK ALAMY / GETTY ISTOCK rather than health and balance, may need extra att ention.
41 COMMUNITY PRACTITIONER | MAY 20188
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THE VEGAN PARENT Tanith Carey, parenting writer and journalist
I really don’t have a problem with raising vegan children. I’ve been vegetarian for most of my life, and my daughters and I fi nally became vegan a couple of years ago. When anyone starts arguing with us it’s like water off a duck’s back. Th ere are amazing substitutes for the things we miss – burgers, cheese and all kinds of things. What people don’t realise is how easy it is to be a vegan because there’s so much product development in things such as chocolate and milk. It isn’t particularly expensive either, compared with the price of meat and fi sh. I give my daughters THE MEAT ADVOCATE vegan multivitamins, including iron and Carrie Ruxton, B12, just to keep everything covered, but dietitian and member of the Meat Advisory Panel it’s mainly for my peace of mind – I’d be giving them supplements even if they A vegan diet isn’t an that protein is important. Soya is the weren’t vegan. And they’re certainly optimal diet for children. only natural plant food that has all nine having loads more vegetables and fruit. Children have much higher of the essential amino acids that make I’d say to any parent: do your research requirements for nutrients up a complete protein, so otherwise you to set your mind at rest, but know that than we do, and if they’re have to combine proteins to get the full plenty of children are being brought starved during those windows of complement. We have nothing in the up vegan. You’re giving your child an opportunity there will be a lifelong UK as extreme as protein malnutrition, incredibly positive start in life, in every impact. Meat, dairy and fi sh are some of but it is much harder as a vegan to way. Among the medical community, the most important give children varied, many adhere to the old-fashioned food food groups around. combined protein. triangle with meat and dairy at the top of I’m not saying children ‘LIFELONG VEGANS Lifelong vegans are it, and there are a lot of vested interests are going to be ill or ARE USED TO THE used to the different in keeping that triangle going. But that diseased but you may buying and cooking triangle needs to be inverted, with fruit put your child at a DIFFERENT BUYING to provide everything and vegetables at the top. I think that in growth disadvantage. AND COOKING you need, but people around fi ve years people will be asking Th e evidence shows TO PROVIDE who’ve just turned ‘What’s the big deal?’ and in 10 years that children who vegan or want to try it they’ll be embarrassed about eating meat. drink plant-based EVERYTHING YOU aren’t. As a rule, with I feel that my children are improving the milks are shorter than NEED, BUT THOSE the fi rst group you’re world in so many ways – it’s win-win on average, for instance JUST TURNED trying to minimise everyy count. (Morency et al, 2017). the harm to that child Small children need VEGAN AREN’T’ because you’re never more calories per kilo going to talk them of body weight than out of it – the second adults; they’re little powerhouses, but is the one that I think does need to be they can also be picky or get ill. It’s headed off. But even when parents are hard enough even on a varied diet to implementing the diet properly, the get everything they need into them. key nutrients of concern in a vegan diet Th ey also need protein – up to twice remain vitamin B12, vitamin D, iron, the requirement per kilo of bodyweight zinc, iodine and long-chain omega-3 that adults do – because they’re fatty acids… and all of these are found constantly growing, and the quality of in red meat.
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THE WARY PROFESSOR Mary Fewtrell, professor of paediatric nutrition, UCL Great Ormond Street Institute of Child Health
Paediatricians is that there are some things which can become a huge used to say vegan you just can’t get. As your issue – people can assume that diets should be diet becomes more restricted rice ‘milks’ and similar drinks banned, and in and you’re cutting out more are somehow the same as some countries things, you have to become formula – and you also have to there’s especially strong more informed. commit a fair amount of time feeling against veganism from Th e particular concern in to planning diet. professionals; but in the end the case of young children Some families don’t you can’t stop people going and babies is that their brains engage with healthcare ahead with veganism, so it’s are growing at such a rapid professionals at all – and more important that they rate and they’re completely those, unfortunately, are the should know where to get reliant on others. Small most worrying. However, I advice. And then it’s equally babies are at particular risk certainly wouldn’t want to important that they actually of B12 defi ciency, and if their suggest that all families are follow that advice. mothers are defi cient too like that. Th ere’s not much research there’s a serious risk of brain Overall, with veganism, on veganism in children, but damage (Guez et al, 2012). So there are quite a lot of areas it’s pretty clear that as a diet it’s essential to supplement, where people need advice, becomes more restricted, and you also have to make sure and there are certainly many you’re going to be at risk of that babies and toddlers aren’t sensible guidelines available. losing nutrients and the more eating an unsuitable high- Th ey do need to follow those attention you have to pay. fi bre, low-fat diet. You need to guidelinesidelines because there are Th e problem with vegan diets think about things like milk, riskskks if yyouou dondon’t.’t.
DID YOU KNOW..?
The term ‘vegan’‘vegan’ was ffirstirst used 100g ooff in 1944, when the VeVegangan Society sspinachpinach wwasas esestablishedtablished inin thethe UKUK ccontainsontainnns 22.7mg.7mg oof iron. 100g100g of FFamousamous vevegansgans today iincludenclude red meatat contacontainsins 22.6mg..6mg.g BButut the iron in spinachspinach is BradBrad PittPitt USEFUL less easeasilyily absorbed RESOURCES (USDA,(USDA, 2018)2018) The Vegan Society vegansociety.com BBenjaminenjamin Many wines are not veganvegan British Dietetic MileyMilMilel y CCyrusCyrus ZeZephaniahephaniahepha and contacontainin iisinglasssinglass – a Association bda.uk.com ffiningining aagentgent made from ffishish bbladdersladders NHS advice on vegetarian and vegan babies and children bit.ly/NHS_vegan
For full references, visit bit.ly/CP_features
43 CCOCOMMUNITYOMMUNITTY PRPRACTITIONERACTITIONER | MAMAYY 2018
40-4 an i .indd 4 26/04/2018 18:20 RESEARCH
ABRIDGED VERSION ASSISTING YOUNG PEOPLE IN CARE Una Foye, Emily Satinsky, Camilla Rosan and Josefien Breedvelt examine the My Life, My Future programme that was set up to boost the emotional wellbeing and resilience of looked-aft er young people.
RESEARCH In 2017, 72,670 young people were in care care (Centre for Social Justice, 2008). in England, with 74% living in foster care A review of child and adolescent mental SUMMARY (Department for Education (DfE), 2017). health services identifi ed unmet mental Significant inequality in levels Signifi cant inequalities exist in educational health needs of young people in care of att ainment, employment attainment and emotional wellbeing for this (Department of Health, 2008). In response, and exclusion from school exist population: DfE and the Offi ce for National NICE set targets to promote aspirations and between young people in care Statistics (ONS) found that young people ensure the emotional wellbeing of looked- and the general population. in care had considerably lower educational after children and young people (NICE, 2013). The My Life, My Future project attainment than young people not in care As shown by Fisher et al (2009), there is a was set up in 2015 to support with reading, writing and maths (48% lack of evidence-based group interventions young people in care (or reached the expected level against 79%), for young people in care. Th ough past looked-aft er children) in Sutt on, and signifi cantly lower rates of achieving trials have successfully introduced group south London. fi ve A* to C grades at GCSE (12% against programming to improve educational The 18-month programme aimed 52.1%) (DfE and ONS, 2014). Levels of attainment of young people in care (Fisher et to increase their confidence in exclusion were also twice as high as those of al, 2009), few programmes have specifi cally themselves and their abilities, the general population. focused on social and emotional outcomes. to maintain their emotional Young people in care In response to the wellbeing and resilience, and are more vulnerable PARTICIPANTS SAID lack of co-produced, to promote development of to mental health evidence-based their aspirations. problems (Hannon, THAT ATTENDING THE interventions My Life, My Future had a et al, 2010; Blower et GROUP HELPED MAKE engaging young positive impact on participants’ al, 2004), with 45% THEM THINK ABOUT people in care, the wellbeing, with increased to 50% of fi ve- to My Life, My Future confidence, aspirations, more 17-year-olds assessed THEIR FUTURES IN A programme was positive family relationships as having at least one POSITIVE WAY developed. It began and personal development. psychiatric disorder. in 2015 and involved By teaching them skills to Rates of poor mental young people in care navigate challenges in their health rise too, to in the Sutton area. lives, the programme improved over 60% (Meltzer et al, 2003; Richardson Th e 18-month programme aimed to increase participants’ resilience and and Joughin, 2000). Similarly, risk-taking young people’s confi dence in themselves their sense of identity. behaviour including substance misuse and and their abilities, maintain emotional Further research with larger unsafe sexual activity are signifi cantly higher wellbeing and resilience, and promote and more diverse sample sizes in young people in and leaving care – 23% of development of aspirations. Th e programme is required. the adult prison population was previously in targeted young people in care between
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the ages of 11 and 15, as children Th e results showed that My Life, My Future had a in this age range share several positive impact on participants’ wellbeing with increases developmental transitions (Erikson, Core topics in confi dence, aspirations, positive family relationships 1993). It focused on educational and for My Life, and personal development. Young people consistently personal development, and accepted My Future referred to sessions as ‘good’ and ‘cool’, and carers self-referrals and referrals from observed that participants enjoyed attending the group. healthcare professionals. Even on ‘bad days’, participants still wanted to attend, Th e weekly sessions were as the group improved negative moods. Participants and designed to be interactive, carers unanimously agreed that they would recommend the engaging and creative. programme to other young people in care. Plans/ Exercises included painting, Participants found the increased positive aspirations baking, craftwork, and relationships and connectedness with other group activities such as ice skating, members to be particularly salient. Young people Social go-karting and trampolining. noted that the friendships formed within the networks Th e structure was consistent group were more personal. When discussing this – check-in (20 minutes); icebreaker connectedness, two of the young people referred (10 minutes); topic for discussion to the group as a family. Th ese relationships (45 minutes); lunch and informal positively infl uenced participants’ lives and self- catch-up (30 minutes); and check Identity assurance, with carers refl ecting that the group increased out (10 minutes) and were co- the young people’s ability to connect with others. Th is was facilitated by two trained youth enhanced by the group structure, which focused on treating workers who modelled responsive Stereotyping/ participants as individuals rather than as young people in relationships using a partnership prejudice care. While the initial proposal suggested a group size of 20 approach (Davis et al, 2002) to 25, the fi ndings suggest increased benefi t from the small and mentalisation principles group size as this further encouraged connectedness. (Bateman and Fonagy, Th e group created a safe space, allowing participants to 2013). Facilitators built Respect talk openly about their emotions and increasing their rapport and enabled perceptions of trust. One participant stressed how the participants to gain Emotions: other participants listened to everything he said and confi dence by modelling happiness, respected his privacy, in stark contrast to his peers refl ective listening. stress, anger at school. Participants said the group helped them POSITIVE RESULTS understand how to deal with challenges in life. Of the 12 young people who By teaching skills to navigate these challenges, the participated in the programme, Peer pressure programme improved their resilience and identity. only those who attended more Young people were asked to score their confi dence on than three sessions were invited a zero to 10 scale – with zero representing no confi dence to take part in data collection. Th e and 10 representing high confi dence – before and after evaluation included six young people attending the group. On average, following a year of (four females and two males aged 13 attendance, young people had a minimum increase in to 15) all of whom attended the confi dence of 30%, with two of the young people reporting group from baseline to the Relationships a 70% increase. Carers observed changes in participants’ 12-month point when the ability to communicate openly and confi dently. evaluation was conducted. Participants said that attending the group helped make Attendance was over 85%. Bullying/ them consider their futures. Th ree young people noted Two foster carers also took cyberbullying defi nitive development of aspirations, while the other part in the evaluation: one three formed vague ideas of where they wanted to be was a foster carer for two of in the future. Th ese ideas changed as they learned more the female participants, and about themselves. One participant reported that the the other was a foster carer for the increased future-thinking prevented her being two male participants. excluded from school. To ensure confi dentiality and blind Grooming/ evaluation, staff were not involved in child sexual FUTURE RESEARCH data collection. All participants were exploitation While all participants and carers reported positive assigned individual codes to protect experiences in the group, areas for improvement their anonymity. were identifi ed. Some participants reported a lack of
45 COMMUNITYCOMMUNITY PRACTITIONER PRACTITIONER | FEBRUARY | MAY 2018 2018
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interest in bullying as a topic as they had no related experiences. Th ree participants suggested including topics more applicable to real life, such as crime, alcohol and drugs. Another participant thought it would be good to mix age groups to help younger members learn from older or past members and care leavers. Th e personal and in-depth nature of some of the sessions allowed participants to share experiences, however, one young person pointed this out as a negative, as some of the topics were potentially too raw for peer discussion. Th eir own experiences of domestic violence and bullying made certain topics diffi cult. Th is refl ects the need to be mindful of subjective experiences and empathetic towards sensitive issues. By employing supportive staff, the programme created a children were in care in England in 2017 peer-based environment with refl ective mentors. Mentors are instrumental in keeping young people in care on track and in helping youth towards positive development (Hass and Graydon, 2009). In fact, research has demonstrated that adult mentors during adolescence increase positive adjustment and other developmental outcomes in adulthood (Ahrens et al, 2008). My Life, My Future participants benefi ted from the peer-focused model, which boosted connectedness, 40% reduced isolation and increased feelings of support. Th ese of care leavers in turn resulted in better emotional wellbeing. Th e ndingsfi aged 19 to 21 are not in education, refl ect those of a randomised controlled trial conducted 23% employment or with 67 adolescents with mental health challenges in foster of the adult prison training, compared care (Geenen et al, 2015). Th rough interactions with their population were with 13% of those in programme mentor and peers, participants experienced previously in care that age group increases in levels of self-determination, mental health, hopefulness and empowerment (Geenen et al, 2015). By including young people in the formative work, the programme team successfully developed a group-based programme relevant to the interests and needs of the population. Th is research has several limitations, particularly its small sample size: quantitative analyses assessing changes in confi dence, wellbeing and aspirations would have added rigour, and the sample size limits validity and generalisability. In addition, the sample only included young people engaged with the programme. Attempts at recruiting young people who disengaged from the service or had poor attendance were unsuccessful and, as a result, fi ndings may not accurately refl ect service effectiveness. 1 in 5 Future research should include larger, more diverse samples, female care leavers have a baby when they are a teenager such as in rural areas or with different age groups, and reliable quantitative measures to assess validity and generalisability. Longitudinal measures can better evaluate long-term effectiveness on the lives and futures of these young people. 4-5x Dr Una Foye is the research officer; Emily Satinsky is Care leavers are four to the public mental health research assistant; Dr Camilla fi ve times more likely to Rosan is the programme lead for families, children and harm themselves than young people; and Josefien Breedvelt is the research other young people DfE and ONS, 2017; NAO, 2016; Meltzer, 2003 2017; NAO, DfE and ONS, manager, all at the Mental Health Foundation.
To view references and the full version of this paper, entitled Evaluating group work for supporting the emotional wellbeing of young people in care, go to bit.ly/CP_research_satinsky
46 COMMUNITY PRACTITIONER | MAY 2018
44-46 RESEARCH.indd 46 27/04/2018 12:34 YOUR JOURNAL NEEDS YOU!
TheThe hhearteart ooff Community Practitionerr is all about you – reflectingeflecting your o life and work wo k as healthcare healthca e professionals. p ofessionals If you’ve been working on a research paper you’d love to see published, we would love to hear from you! Please get in touch with assistant editor Hollie Ewers at [email protected]
47 in- s ad all a s.indd 47 26/04/2018 18:27 PROFESSIONAL PA SE
n estimated 127,000 peoplee in the UK, or around one inn 500 of the population, havee A Parkinson’s (NHS Choices, 2018), and the number is on the rise. While there are treatments available to help manage the condition, theree is still no cure. Parkinson’s generally strikes when people are in their sixties or seventies and well on their way to retirement. But about 5% of people diagnosed are younger than 40 and still in the middle of their working careers and/or bringing up children (NHS Choices, 2018). Th e problems they face are signifi cantly different to those of the older generation.
WHAT ARE THE PROBLEMS? Being told you have Parkinson’s is bad enough in your twilight years, when you are wearily resigned to the limitations and infi rmities of looming old age. But getting a diagnosis when you are still immersed in the daily struggle of full-time employment and the demands of being a parent presents a more challenging set of diffi culties. First and foremost for many will be the prospect of losing their job. Th e impact on their partner and children will be a major consideration. For some young couples, Parkinson’s poses the heartbreaking dilemma of whether or not they should begin a family in the fi rst place. Coping with these issues might be complicated by the fact that the worst symptoms of Parkinson’s are often not immediately obvious. It can be many years DO I NEED before Parkinson’s begins to take its toll. Even when the symptoms take hold, the medication can be extraordinarily effective in disguising the condition. So much so that it is quite common for people to kid TO TELL themselves into thinking that they don’t really have a problem, or that somehow they will prove to be the exception to the rule. Inevitably, however, there will come a time when they wonder whether they MY BOSS? should tell their employer. Are they legally required to do so? Must they inform a potential employer of their condition? What Writer Tim Carroll discusses the issues if they become too incapacitated to work, or encountered by people diagnosed with they decide to give up work? Are there any benefi ts they can apply for? Will they be able ‘young-onset’ Parkinson’s. Tim himself was to draw on their pension? diagnosed with the progressive neurological Th ere is so much that is simply not known about Parkinson’s, and the condition condition in his early fift ies.
48 COMMUNITY PRACTITIONER | MAY 2018
48-49 a s .indd 48 26/04/2018 18:29 PROFESSIONAL PA SE
affl icts people in so many different HOW ELSE CAN YOU HELP? ways with multiple degrees of severity. Last year, SLYPN ran a Community practitioners should Community practitioners can help by Plank4Parkinsons campaign, put clients in touch with the charity having a basic knowledge of the support challenging people to hold a plank Parkinson’s UK, which is particularly available for clients with Parkinson’s. position for one minute – the tired helpful with emotional concerns in the muscles and consequent cramping, family. It has put together four books THE OPTIONS aching or shaking offers a for younger children, as well as a guide Being diagnosed with Parkinson’s does glimpse of life with Parkinson’s. for teenagers. not mean giving up work. It is possible, Dozens of groups throughout the UK also depending on the extent of symptoms and cater for the requirements of young people with the success with which they are managed, that Parkinson’s. Th e South London Younger Parkinson’s a person with Parkinson’s could continue to work Network (SLYPN), for instance, organises social events for many years. And people are not required to inform and fundraisers for Parkinson’s UK (see graphic, left). their manager that they have Parkinson’s unless it is What about starting a family? Th ere are so few cases likely to cause health and safety issues or it will require of women with Parkinson’s becoming pregnant that no adjustments to the way they work (Parkinson’s UK, 2018). reliable fi gures exist. Th ere is a limited evidence suggesting If a person does tell them, their right to confi dentiality certain drugs should be avoided. And some doctors are is protected by the Data Protection Act and its successor inclined to advise that no Parkinson’s medication should be from 25 May, General Data Protection Regulation. taken at all. But of those births that have been documented, Th e manager must not tell anyone else without the vast majority end up in successful, full-term delivery of specifi c permission. healthy babies. It’s probably best before becoming pregnant When a person has Parkinson’s, they will probably for women to consult their neurologist, obstetrician and qualify as being disabled under the Equality Act (2010) Parkinson’s nurse. – or the Disability Discrimination Act in Northern Ireland (1995) – meaning it is illegal to discriminate against Tim Carroll is an author and travel writer. someone because of their condition. It takes into account He lives in London with his wife Linda the fl uctuating nature of Parkinson’s and provides and their two children. protection even on days when the person is feeling fi ne. However, people with Parkinson’s may need to change the way in which they work. Th e law makes the employer legally responsible for what are termed ‘reasonable TIME TO REFLECT adjustments’ to the person’s work practices and/or What more could you do to help support workplace. People can arrive at a ‘workplace adjustment clients and their families with young- agreement’ with their employer that will cover the onset Parkinson’s? Or could you share diffi culties they might encounter because of Parkinson’s: any insights? Join in the conversation on for instance, walking, concentrating on work, or holding Twitt er @CommPrac using the hashtag telephone conversations. #YonParkinsons Th ere are numerous possible provisions. A person might be allowed to work from home on some days for instance. Th e company might be legally required to make physical alterations to buildings or provide special equipment, such as a large-buttoned telephone. RESOURCES For those who work for a small fi rm that cannot afford such alterations, it might be possible to get a grant from Find South London Younger Parkinson’s Network a government scheme called Access to Work. If it is at slypn.org.uk impossible to make the reasonable adjustments that they The Parkinson’s UK confidential helpline can help need to continue in their job, their employer is required people with employment, emotional and family to offer ‘redeployment’ in a role that they are capable issues, and more. Call 0808 800 0303 of fulfi lling. For Access to Work, go to gov.uk/access-to-work It’s best to fi rst raise the issue with a manager and (in Northern Ireland, visit nidirect.gov.uk); discuss matters informally. If he or she does not have the for flexible working rights, visit gov.uk/flexible-working power or inclination to act on their behalf, it is important Search pensionsadvisoryservice.org.uk for information to bring the matter to the attention of HR. Th ey can on ill-health retirement or call 0800 011 3797 consult occupational health specialists who will be able to Contact the Disability Law Service at provide the company with an independent and impartial [email protected] and Business Disability Forum assessment of the person’s needs. at [email protected]
49 COMMUNITY PRACTITIONER | MAY 2018
48-49 ProfPause.indd 49 27/04/2018 12:34 PROMOTE YOUR COURSES IN PRINT AND ONLINE AMONG THE MEMBERS OF THE CPHVA CONTACT: GORDANA JEVIC T: +44 (0)20 7324 2735 COURSES E: [email protected]
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Train to become a certifi ed infant massage instructor with the IAIM, the largest and longest-standing worldwide association ANNUAL PROFESSIONAL dedicated solely to baby massage. Our curriculum is taught CONFERENCE in more than 60 countries and has been developed and 2018 refi ned over 30 years through research, refl ective practice and 17-18 OCTOBER practical experience. Th is has resulted in a widely endorsed BOURNEMOUTH INTERNATIONAL CENTRE and implemented parenting programme. By training with our highly respected organisation, you will join a worldwide The Unite-CPHVA conference is an opportunity network of instructors offering a supportive environment to to access your professional communityy on teach lifelong parenting and relaxation skills. a national scale, designed specificallycally to support community practitionersers T: 020 8989 9597 to keep ahead of the ever-changinging E: [email protected] political and professional landscape.ape. W: iaim.org.uk Facebook: IAIM UK Chapter REGISTER NOW ATT CPHVACONFERENCE.CO.UKCOO..UK
0 s s a 2018.indd 0 26/04/2018 18: 0 RECRUITMENT
Health Visitors We have a number of exciting opportunities for Experienced and 5L^S`8\HSPÄLK/LHS[O=PZP[VYZ Full time and part time posts Edinburgh and Lothians
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If joining us on this journey appeals Karen Holmes or Val Alexander, to you and you would like more Clinical Nurse Managers information please visit our website or Tel: 0131 536 8852 for an informal chat, please contact: e: [email protected] [email protected]
CONTACT: KRISTIINA KRUUSMA | TEL: 020 7880 7621 | EMAIL: [email protected]
2018 i m n .indd 1 2 /04/2018 11:29 We are committed to advancing evidence-based best practice for infant skincare Over recent years, Johnson & Johnson Family of Consumer Companies has consistently published more fundamental and clinical research into baby’s skin than any other global health care company.
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