HIFA Discussion: Alcohol Use Disorders - Do people understand the harms of alcohol?

Dear All (with further editing since posting)

The discussion, points, angles, questions ... are coming thick and fast it is difficult to keep up.

Many thanks for the summaries; and of course the discussion which archived also acts as a resource - repository:

https://www.hifa.org/news/hifa-announces-deep-dive-discussion-alcohol-use-disorders-starts-5-february-2024

I wonder whether the question: 

"Do people understand the harms of alcohol?" must always be placed in context?

It is radically different when asked of the tee-total, dry, safe drinker; and someone (still) actually in their alcohol drinking?

It occurs to me that alcohol, even more so than 'other' substance misuse (heroin...) represents what must be *the* contradiction, paradox in healthcare - except the tragic loss that is suicide.

Contrast substance misuse inc. alcohol, with 'help-seeking' and 'The Sick role'

https://www.england.nhs.uk/blog/ed-mitchell-2/

Plus, the (medical) sociology of the decision to consult/refer, and how in mental health (UK), the mental capacity act is apparently being misapplied ('policy-drift'?**):

https://www.lawsociety.org.uk/topics/blogs/are-mental-health-and-capacity-laws-at-risk-of-being-toxic

https://www.communitycare.co.uk/2017/08/23/flawed-use-mental-capacity-act-key-theme-safeguarding-adults-reviews-report-finds/

Individual
   |

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :   POLITICAL 

|

Group

	continental drift
	policy drift?

Previously, I highlighted how as a Community Psychiatric Nurse 1985-1995 (adult) .. if a patient/client was not working to control/reduce their alcohol consumption they may be 'counselled' re a pending discharge and referral back to their GP - family physician. In supervision with the team's manager they would want to know what is 'happening'. It being important not to create (social) dependency, or worse support someone in their alcohol misuse.

There was a sense, still is(?) that in substance misuse (across forms) - the individual has to reach 'rock-bottom', literally the 'gutter' that is the point they decide (really?)** to live, or carry on to suffer irreversible brain damage, or premature death. Regards the 'brain damage' it was a struggle for 45-60 minutes given the impact upon short-term memory, what time, .... is it indeed? When the patient was not living alone, how did the relative, family cope?

Is having to reach the gutter, the bottom, a trope/myth? In psychosis rather than assume the patient is beyond being reached prior to being medicated there are psycho-social interventions that can be commenced: being available / with. Here though this is usually 'first episode'. There is no analogue here, unless first admission to an in-patient unit is taken as a golden opportunity? But this also depends on its nature (funding, staffing - expertise), a general adult mental health ward, or specialist unit.

https://www.imdb.com/title/tt0048347/

What is the current strategy?

In terms of 'HIFA' - and the person that counts**, not only do they not have the 'information'; they do not have the EXISTENTIAL INFORMATION as it relates to them: 'Health Information for YOU'!

Again in Hodges' model we can contrast the dichotomy/polarisation of INDIVIDUAL :: GROUP.

The model's being situated; and able to encompass data, information, knowledge (facts, for example, and their delivery) - wisdom (Multi-contextual / transdisciplinary..).

I admire people who work in these services (learning disability and palliative care); as they must be severely tested as they retain an ability - the humanity - to 'see' the person whatever the patient's situation with their lack of awareness (capacity..?) and its critical salience.

Peter Jones
Community Mental Health Nurse and Researcher
Blogging at "Welcome to the QUAD"
http://hodges-model.blogspot.com/
http://twitter.com/h2cm
h2cmng at yahoo.co.uk

Location: It was just a cappuccino.

**Which points to the relevance of the POLITICAL care/knowledge domain in Hodges' model.

HIFA Discussion: Alcohol Use Disorders - Language 'being drunk'

----- Forwarded message -----
From: Peter Jones, UK <hifa AT hifaforums.org>
To: HIFA - Healthcare Information For All <hifa AT hifaforums.org>
Sent: Sunday, 25 February 2024 at 06:35:47 GMT
Subject: [hifa] Alcohol Use Disorders (86)

This morning on Times Radio UK, Hugo Rifkind 1000-1300 from 10.58:30 UTC:

 https://www.thetimes.co.uk/radio/show/20240224-26978/2024-02-24 

- there was mention of research in Germany on language, finding that there are over 540 words for 'drunkenness' being drunk. Apparently, the key is adding -ed to many words.

https://www.research-in-germany.org/idw-news/en_US/2024/2/2024-02-19__I_m_gonna_get_totally_and_utterly_X-ed.__OR__Can_you_really_use_any_English_word_to_mean__drunk__

This stood out for me as Hodges' model can potentially encompass the full corpus of a language, with the various contexts in which language is applied/used.

Significant of course informationally, in evidence-based practice, and research, were 'definition of terms' are (usually?) essential.

Also reminded of national variation in clinical/medical terminology. Scottish slang for injection includes 'jag'.

For health communication and HIFA, clearly language is fundamental and presents a real 'can of worms' (sorry!) in sense-making, creating 'noise' in the communication channels.

Should health services/systems effect a (gradual) change (shift) of emphasis to education and prevention - with the requisite policy support (utopic?) then this will need to be addressed.

In checking this news, it appears Germany has a more acute problem with alcohol. Can anyone 'local' - please shed any light on this?

I will post again about the HIFA discussion with a week ... left and highlight the above.

Many thanks

Peter Jones
Community Mental Health Nurse and Researcher
CMHT, Prescott House, Salford NW England, UK (Mon-Tues)
Blogging at "Welcome to the QUAD"
http://hodges-model.blogspot.com/
http://twitter.com/h2cm

h2cmuk AT yahoo.co.uk

HIFA discussion on Alcohol Use Disorders, 5 Feb - 17 Mar 2024

Dear all on HIFA,

It's just 4 days to go before the official launch of our deep-dive discussion on Alcohol Use Disorders, 5 February to 17 March 2024.

Please forward this message to your contacts and networks and invite them to join! www.hifa.org/joinhifa

More information here:
https://www.hifa.org/news/hifa-announces-deep-dive-discussion-alcohol-use-disorders-starts-5-february-2024

HIFA is grateful for sponsorship from the Ulrich and Ruth Frank Foundation for International Health known online as NextGenU.org.

Note: We have opportunities for further sponsored discussions in 2024. We have 20 working groups on standby to plan and implement a discussion [ https://www.hifa.org/projects ]. Or we can start a new group to address a topic that is important to you. Also new in 2024 there is the option to have live webinars to complement our forum discussions.

To discuss possibilities, please contact: neil AT hifa.org

With thanks, Neil

HIFA Partnerships and Projects working group: https://www.hifa.org/projects/partnerships-and-projects

HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization.

c/o HSE.ie - Model of Care for People with Mental Disorder and Co-existing Substance Use Disorder (Dual Diagnosis)

"The definition of Dual Diagnosis for this Model of Care is: ‘the co-morbid disorders due to substance use and/or addictive behaviours along with the presence of mental disorder(s)’. The disorders of substance use include disorders of alcohol use." p.10.

Model of Care for People with Mental Disorder and
Co-existing Substance Use Disorder (Dual Diagnosis)

INDIVIDUAL
|
INTERPERSONAL    :     SCIENCES              
HUMANISTIC --------------------------------------  MECHANISTIC
SOCIOLOGY :   POLITICAL
|
GROUP

mental disorder addictive behaviour - inc. gambling and gaming disorder lived experience recovery (here?) [cognitive access: orientation, insight, literacy, communication ..] training patient and	Demographics: Adult Dual Diagnosis team cover population of 300,000 Adolescent Dual Diagnosis teams 10 to 17 years lived experience data gathering p a th w  a ys [ physical access: place, time] e-health, therapeutic modules reablement, recovery (here?)
public involvement Carers Social Inclusion Social capital lived experience Vulnerable women, communities, homeless, ethnic minorities, refugees, recovery (here?) rehabilitation	Dual Diagnosis Service funding [ planned - in-patient beds ] TRAINING Service users lived experience interdepartmental discussion re. service provision for prison population probation services asylum seekers, immigrants Key Performance Indicators recovery (here?)

FOR: Economic, Educational, Environmental, Social, Political DETERMINANTS . .

READ: Cognitive, Physical, Social and Political ACCESS

My source: https://twitter.com/h2cm/status/1661299925391384576?s=20

Patient navigation model - Paper: mapped to h2cm

On twitter I learned of an EU project @CANCERLESS_EU and an initial paper:

 Exploring the application of the navigation model with people experiencing homelessness: a scoping review, Journal of Social Distress and Homelessness, DOI: 10.1080/10530789.2021.2021363

Phrases like 'navigation', 'architecture', 'maps' are a trigger so after some tweets, I was kindly directed to the above paper.

Here, I'm mapping patient navigation and related concepts I have added, to Hodges' model.

"Patient navigation is a community-based and person-centered intervention, whereby a named worker – the navigator – supports and guides individuals to overcome the barriers they face in accessing healthcare services and works to facilitate timely and appropriate access to care for the individual as well as their relatives, and caregivers, when needed (Freeman, 2012; Wang et al., 2015)."

 INDIVIDUAL

|

 INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

psycho- depression, anxiety, distress, trauma (psyche) serious mental health substance misuse dual diagnosis vulnerability isolated difficult to engage, missing appointments, no designated point of access - Address Personally reliant on welfare/benefits for finance - phone contact sporadic. providing emotional support, phone, transport Hit by energy costs/rent (pre-payment) if finding a place. hopelessness, lack of trust - let down many times? Stigmatized attitudes towards treatment? tailored health education asocial (due to lived experience, trauma..?)

-geography low-income areas, or areas with a high proportion of ethnic minorities or migrants USA - other nations - terminology? method: scoping review, literature search, inc. exc criteria interventions tailored to age and gender respiratory conditions, trauma (physical) excess winter mortality "homeless population having an average age at death of just 47, 30 years lower than that for the general population" exposure to activities known to increase risk of cancer HIV patients data - inc. no-show rates in-person / phone Timeliness of screening, intervention

Navigators - lay persons, or clinical professionals Lived experience, "near peer" family Training for Navigators organizing and attending appointments and facilitating self-care/self-management clinical and community settings, parks, pavements, and homeless encampments, home visits, walking and support groups *risk of stigmatization and experienced discrimination navigation less successful with certain groups?

Underserved, marginalized people Homelessness High-risk of poor health-related outcomes reported barriers access to appropriate healthcare for this population are also often compounded by lack of insurance, legal problems*... ...the PN model has been associated with a reduction in hospital costs, and even in some cases, increased revenue histories of offending and/or care women in rural areas non-specific vulnerable populations reduce incarceration, vocational and volunteering activities, access to housing

Christina Carmichael, Lee Smith, Edelweiss Aldasoro, Alejandro Gil Salmerón, Tamara Alhambra-Borrás, Ascensión Doñate-Martínez, Radhika Seiler-Ramadas & Igor Grabovac (2022) Exploring the application of the navigation model with people experiencing homelessness: a scoping review, Journal of Social Distress and Homelessness, DOI: 10.1080/10530789.2021.2021363

Re-Inventing Schizophrenia: Updating the Construct

INDIVIDUAL

|

 INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

Schizophrenia Research
	Re-Inventing Schizophrenia: Updating the Construct

Re-Inventing Schizophrenia: Updating the Construct. Edited by Rajiv Tandon, Matcheri Keshavan, Henry Nasrallah. Schizophrenia Research. Volume 242, Pages 1-150 (April 2022).

My source:
https://twitter.com/JeroticStefan/status/1508898715473530888?s=20&t=X61DSrPzEyLvX-FhzY5r-A

Need for bio-psycho-socio-POLITICAL perspectives - spiritual too.

Previously on W2tQ: DSM

 

An atmospheric inversion

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

	.. a t m o s p h e r e .. ........................ methane and carbon dioxide at record levels We need to take care
.. a t m o s p h e r e .. ....................... nitrous oxide You need to take care

Prompt:

World Week in Review, Methane and carbon dioxide in atmosphere rise to record levels, FT Weekend, 10-11 April, 2021, p.4.

Inverse Care Law ... at Social Care's Door

Since 2015 I've had four 'conversations' with the doctors at A&E upon mum's attendance and subsequent admission on a couple of occasions. Initially, I was surprised if not shocked by the speed with which the 'conversation' followed on treatment, the extent of this and the question of resus. The further interactions were still emotionally jarring, even when expected and telegraphed. I also understand: to an extent. Repeated chest infection or urine infection had resulted in confusion, delirium that varied. on one occasion, at the nursing home there was also suddenly talk of a diagnosis of dementia, which prompted social services to wonder, like family and staff, where exactly this diagnosis had come from and investigate. (Another post?)

Mum has been very poorly, most recently in November. What surprised and shocked was the 'conversation' at the end of the bed when I knew mum - with mental capacity at that time was most likely listening. The primacy of person-centredness seemed to be by-passed. I suggested the doctor ask mum since once hydrated she would be fine. There has been a sense of a script being followed with some pressure - urgency behind it, if not a 'prescription'. I empathised with the doctors, often FY1 FY2; such matters are never easy. Now amid COVID-19 there is alarm as social care are challenged with taking on a new role, for which they are ill-equipped. 

In health care you are always conscious of the inverse care law, it seems there is another care law in operation that gives cause to worry for those who cannot advocate for themselves or have no independent advocate. Perhaps there is another inverse law that runs concurrently concerning ethics. Triage, is real. Objectively, as a nurse you think "Am I being selfish?". But, as eldest son - absolutely not. These conversations, and the future aside, the doctors and team as a whole have worked (absolute) wonders for which mum and the family will always be grateful.

Be Well, Be Safe All.

 

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

"There should be no wrong door and every  service should reverse the ...	... Inverse Care Law, which simply states those people in need of health and social care the most  get them the least."
https://www.smithsltd.co.uk/doors/composite	By MrPanyGoff - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19702555

A comment at The King’s Fund, by Lord Victor Adebowale.

Partnership Working, Time to Talk, Drink and Drugs News, October 2018, pp.10-11
https://drinkanddrugsnews.com/wp-content/uploads/2018/10/DDN-October-2018.pdf

If anyone has a photo of a red door at a care or nursing home that I can display above please let me know.

Stranger in a strange land: 'Adult' CMHT

I've started working in an 'adult' community mental health team. This is a change in character from older adults and in Hodges' model we can draw the discussion on this out in several directions.

The 'adult' - 'older adult' distinction on one hand may seem discriminatory. So, once you are aged 65 you move to another service? On the other hand there are many scholars / professionals who have over many decades fought to have older people's needs recognised, represented and funded as a distinct speciality. There are protocols accepted and practiced that should - must also take into account the patients (carers) wishes allied with needs and circumstances.

The 'character' is also different between adult - older adult, but both carry unique challenges*. This must always be the case if the patients and their situation are viewed as unique.

3.5 days in - I'm already aware of changes in community mental health provision. My previous experience 16-65 goes back to 1995, apart from having some patients during studies in psychosocial intervention in psychosis.

There seems to be more chronicity and I have a sense that suddenly 'nursing' has a welfare and benefits problem solving flavour to it.

The summit I've just posted about is invaluable learning, as I have inherited a caseload of people living with varying forms of diagnosed personality disorder. I'll expand on this experience over the next few weeks. This is timely as I have re-validation next year.

Over many years I have heard of Paris the clinical record system. Now I will be having training and become a 'user'. Looking forward ...

*With challenges also come rewards!

iii RCGP’s 7th Health and Justice Summit ...

Returning to Juliet Lyon CBE, Chair of the Independent Advisory Panel on Deaths in Custody, who presented ‘Keeping Safe – how consultation with women and men in prison and health and justice professionals informs our work and advice to ministers.’

In February this year the Independent Advisory Panel on Deaths in Custody (IAP) and the national newspaper for people in prison, Inside Time, began a ground-breaking collaboration - Keeping Safe - to help keep people in prison safe. Supported by the Samaritans and Prison Radio, the IAP called on Inside Time readers to say how best to prevent suicide and self-harm. Prisoners’ recommendations in this Inside Time special report reflect evidence from, and recommendations made repeatedly by, amongst others, the Prisons and Probation Ombudsman, HM Chief Inspector of Prisons, the Chief Coroner and the National Audit Office.

Ms Lyon spoke of the clinical context, hope and time:

What was done in the  ::   Being in Prison  ::    What might be done in the

Past                        Now                             Future

Mention was made of a 'Keeping Safe' event in February 2020. If I learn more, I will add details.

Mark Langridge took us through some technology developments in healthcare as Care UK National Lead Pharmacist:

Socrates (with reference to 5-domains of well-being)
PharmaSelf24
PrisonAssist
Turning-On

There was discussion of "Opt-out" in respect to population screening for antibody positive screening tests and how the question is framed:

"Want your bloods done, luv?"

"We test everyone because    ...

is that OK with you?"

On day 2 Suzy Diamond-White, Governor at HMP Eastwood Park shared management experiences and the quest for change in ‘Delivering Health and Wellbeing in a Women’s Prison’

A look at how health services are delivered within the operational demands of daily life at Eastwood Park given its complex population and wide geographical catchment area. How we keep wellbeing on the agenda to support our contracted health teams. What is so specific about a women’s prison? What needs to be overcome to ensure equivalent service to the community.

Gender was obviously fundamental here, the fit and appropriateness of P.E. kits, the procurement and supply of sanitary towels and incontinence pads. What is 'hygiene' being accounted for through a 'cleaning' budget and other historical legacies to be challenged. The geographical range of Eastwood Park across nine counties and all the consequences for family and children. Talk of prison as a punishment and the public's view was echoed a few times at the summit.

Elizabeth Moody, Deputy Ombudsman at Prisons and Probation Ombudsman provided more reflection on deaths in custody, stressing the families affected by and need for action and lessons to be learned. High profile cases were mentioned in several presentations. The talk gave me a sense on one hand of what families must go through, especially when circumstances suddenly engulfs an individual in the criminal justice system. The work that independent agencies do behind the headlines and sometimes in the midst of them

Chantal Edge, NIHR Clinical Doctoral Research Fellow for Department of Epidemiology and Public Health described research on “Systems barriers to telemedicine in prisons”.

Experiences of systems barriers (prison and hospital/community) encountered in England whilst attempting to operationalise a local prison-hospital telemedicine model, alongside broader evidence on prison telemedicine implementation barriers drawn from a systematic qualitative literature review of published prison telemedicine evidence.

I was late arriving to this session. As per my thoughts concerning Dr Matthew Langley's presentation the potential socio-technical studies might provide some insights?

Although it is also a commercial vehicle, Raconteur published with The Times had a special report on 5G in June. In a similar way to my references to the 5-Care-Domains of Hodges' model, many people talk of 5G and its speed, without fully understanding the change and opportunities this can bring. The report's summary:

"5G is so much more than faster 4G, but the extraordinary hype surrounding it has left many confused over what it will actually do for them. The 5G special report, published in The Times aims to shine light on this, exploring how 5G can transform healthcare and make smart roads a reality ahead of autonomous cars. It covers how to address public concerns over the health impacts of 5G and examines whether the rush to be first in the 5G race is a fool’s errand, with comment on how it might be better to deploy 5G best, rather than deploy it first. Also featured is an infographic measuring the true impact of 5G and looking at the sectors which stand to benefit the most ..."

Chantal provided some copies of an associated paper:

Edge, C., Black, G., King, E., George, J., Patel, S., & Hayward, A. (2019). Improving care quality with prison telemedicine: The effects of context and multiplicity on successful implementation and use. Journal of Telemedicine and Telecare. https://doi.org/10.1177/1357633X19869131

Rachel Gibbs "Equalizing Spaces"

Rachel Gibbs, Assistant Director for Prison Healthcare Services for Northern Ireland shared a travel fellowship “Equalising Spaces”.

Rachel Gibbs was awarded a Winston Churchill Memorial Trust Fellowship in 2019. She will share learning from her visits to Prison Healthcare services/Transitions clinics/Harm reduction rooms in California, North Dakota, New York, Barcelona, Geneva and Stockholm over an eight week period in order to being back innovative ideas to the UK. She will share some of the user involvement work happening in Northern Ireland.

Churchill Fellowship

The title of this session including 'spaces' had my immediate attention and did not disappoint. Rachel's Gibbs also provided help in making me feel a little less guilty in the future. Rachel highlighted and reminded me of the value of travel in the exchange, transfusion and diffusion of ideas, a difficult equation to resolve in these flight-shaming days.

Rachel Gibbs - findings

I do wonder what a global consensus would be on models of care, nursing theory and what other continents have to say (if anything?) on this topic that might inform my study of Hodges' model. Rachel recounted her travels and learning not just from her peers but from prisoners and ex-prisoners. Existing awareness of international health and justice provision was used to focus countries to visit.

Rachel shared her time with:

Transitions Clinic Network (TCN), USA.

and 

One Day at a time
Empowering youth to lead positive lives

Hodges' model repeatedly 'takes' me to spaces of all kinds and also transitions:

Life course - infant - child - teens - adult - older adult - end of life

Life course - infant - child - teens - adult - older adult - end of life :: Diagnosis X (Rare?)

Health - Social Care

Critical information giving :: Pre - Post

Adult service - Older Adult Services

Looked after Children - Adult

Younger Adult, Adult, Older Adult :: Early Onset Dementia

Home care - Day care - Respite care - Residential Care

Continuing Health Care

Justice and Health

Veteran - Civilian

Risk

Formative education - Lifelong learning

Health - Trauma - Intensive Treatment - Return Home

and other Transitions (Prevention!) ...

We often think of tools and the need for them to be ready to hand, as in organising your workspace. Increasingly as the list above suggests there is a need for tools to help keep things 'close to mind' also.

Professor Graeme Henderson (School of Physiology, Pharmacology and Neuroscience for The University of Bristol) gave a serious and yet entertaining talk on“Why are fentanyls so deadly?”

Fentanyls are highly potent opioid agonists. Only small quantities are required to produce their effects and this may make them attractive drugs for smuggling into prisons. fentanyls have pharmacological properties that make them more likely to lead to overdose than other opioids – in addition to their high potency and rapid onset of action these drugs induce respiratory muscle stiffness making it difficult to breath, are less sensitive than heroin to naloxone reversal and may show reduced cross tolerance to other opioids.

Prof Henderson provided statistics that had you paying notice, supporting the first answers to the title:

• High potency
• Faster rate of onset of respiratory depression
• Muscle stiffness (wooden chest) making it harder to breathe
• Lower cross tolerance between heroin and fentanyl
• Resistance to naloxone reversal

The Chairs for the summit had quite rightly drew delegates attention to the exhibitors, so I was a bit late again here. The photo is not very good, but brings home the potency of fentanyl. (That is Prof Henderson in the biohazard suit.)

... (still) to be completed - part iv to follow ...

ii RCGP’s 7th Health and Justice Summit: Journeys Through Justice – Leadership and Transformation

Before moving to day 2 ...

- the keynote by Cllr Asher Craig Deputy Mayor (Communities, Equalities & Public Health) at St George West Ward and Bristol City Council provided a city-wide perspective on public health, public mental health, the lived experience of child poverty and with it adverse childhood experiences, the impact of institutional racism and deaths in custody. I've taken more notice locally of community initiatives and sadly note speaking to what was once a local authority day care centre is now a social enterprise with uncertainty about its future. Cllr Craig spoke of Bristol's One City Approach and Learning Circles.

I attended Dr James Matheson's workshop, a GP at Hill Top Surgery and three medical students at Manchester Medical School - “Resources for primary care support to people in contact with the criminal justice system and their equally-affected others”

"Whilst the GP workforce is short, never have we had so many GPs in training. Is general training enough without extra specialist skills training on top? How then do we create and deliver a curriculum to inspire and prepare the next generation adequately for the challenges they will face?"

With posts to follow reviewing Kinchin's book the care environment presented by prison health  seems to encourage a network approach to learning, not merely linear - procedural - chain like approaches. As air safety methods demonstrate (outside of recent design?) checklists have their vital place as a heuristic and decision-making algorithm, but prison immediately challenges a student's attitudes, their expectations of themselves and others. Meeting prisoners crystalises a focus on self-awareness, what is subjective, objective, verbal and non-verbal communication. As per the synopsis the enthusiasm and feedback of the students to their learning was great to hear.

In addition to the student's contributions Dr Matheson highlighted inequality and referenced the "Deaths of Despair" that we have reached.

Another by Dr Matthew Langley, Consultant Forensic Psychiatrist for Rampton Hospital addressed:
“Remote vital signs and activity monitoring”.

"Early experiences with remote vital signs monitoring technology in High Secure (Women’s) Coral Ward (NHSHSW) is trialling Lio Health (Oxehealth)’s remote vital signs and activity monitoring system. This is an innovative solution to support our staff but also presents challenges to integrate effectively. This presentation will discuss initial feedback from staff and patients and investigate our experience as a service with this new technology."

This project was already underway when Dr Langley returned to work at Rampton. Apparently the technology is very effective, Dr Langley trying it himself. Risk is a cost-rationaliser and here the risk is acute. Generally in health care professionals will need to weigh the ethical pressures in adopting technology. Technology will be a factor in making health care (and universal health care) sustainable, but as with electronic health records and their benefits the latter need to be assured. Does a technology 'solution' really free senior staff to focus on more 'complex' work?

I did not ask in session Dr Langley about his awareness of work on socio-technical approaches and Enid Mumford's work. At coffee we had a chat and will follow up with some information. I am very much an advocate for technology - students expect no less, the public look at what we do, the way we work and rightly wonder: wither the technology?

Another concern, however, is the word 'recognition'. Facial recognition is already politically and ethically loaded. States are deploying this technology with 'emotional recognition', so careful consideration and critique is needed (imho).

Sarah Bromley, National Medical Director Health in Justice at Care UK, covered:
“Patient Safety and Quality in Prisons”

"Deaths in Custody are still rising and the PPO have identified repeat recommendations that continue to contribute to deaths. How do we learn lessons and implement change and how do we know when we have been successful. Dr Sarah Bromley will discuss the challenges faced, the Care UK PROTECT programme and quality assurance measures in use."

Sarah appealed to my 'information-oriented' focus, as it was noted how teams can still reach a point with a new referral / patient ' client and question:

"Have we got more information"?

"No."

"Oh, right."

They then elect to carry on without this (acute - in contrast to the uncertainty it represents?) need being pursued and fulfilled. A useful distinction was made by Sarah between training for staff - Wellbeing approach, ASSIST training 2-days on self-harm and suicidality, TRIM training; and support for staff who experience extreme trauma, clinical supervision and clinical forums.

There are subjects that need regular update and so I was very grateful for:

Dr Iain Brew, Deputy National Medical Director of Health in Justice Medicines Safety and
“Hepatitis C – developments and outcomes”.

This was very helpful personally as a nurse, and in the national and global objectives that have been set. With Hodges' model incorporating an individual -- group (population) axis and a Political care domain two further talks were greatly appreciated:

Juliet Lyon CBE, Chair of the Independent Advisory Panel on Deaths in Custody, who presented ‘Keeping Safe – how consultation with women and men in prison and health and justice professionals informs our work and advice to ministers.’ Ms Lyon explained feedback from prisoners on how "... you get the odd officer who really takes care and really wants to do something but there should be an officer on every landing who spends at least twenty minutes with one prisoner at a time through the time he is there and understand him and get to know him rather him just being a number ...".

A comment Ms Lyon made concerned the training of prison officers. The time is limited. I spoke briefly to Ms Lyon as there is a resource that imho should be a part of all course 101's and again I will reach for the email. This resource might help many prisoners too. One of the needs identified was prevention, improving prisoner - officer relationships and preparation for release. It must surely help in all of these if prisoners themselves were better equipped to reflect and have a better relationship with themselves? Self-esteem counts for a great deal and whether inside or out it seems many prisoner's self-esteem is challenged, even if sufficiently coherent and emotionally mature?

A quote also struck a chord: "All my life just got the better of me since aged 13" and a self-harmer.

And, Dr Brad Hillier, Consultant Forensic Psychiatrist at Heathrow Immigration and Removal Centres on “Mental Health and Substance Misuse in the Immigration Estate”. A topic that is clinically remote to me and yet conceptually 'visible'. Visible through geopsychiatry, the impacts of conflict, enforced migration.

Dr Hillier outlined the history of immigration removal in the UK from "Immigration Act Prisoners"
1970 - small detention unit in Harmondsworth, similar units in Dover and Gatwick.
Most IAPs held in prisons (180 in 1982).
1993 - Campsfield House converted from prison to IRC
Current system dates from around 2001-6
Home Office Policy to detain and deport developed
Detention Centre Rules (2001 - statutory instrument)
Immigration Detainees

More background on 'Routes into Detention'; the impact of detention on mental health (Von Werthem et al. 2018; Adult at Risk and Rule 35 - consideration for release on medical/professional evidence that there is a history/evidence of

• Torture/trauma
• self-harm
• Health condition (mental and physical) ...;

and Issues on removal / release.

This insight was new for me.

Although the programme is primarily divided between plenary sessions and workshops, the workshops - at least those I attended are essentially presentations. The room layouts reflected this. A workshop for me should have an audience work.

More to follow ...

i RCGP’s 7th Health and Justice Summit: Journeys Through Justice – Leadership and Transformation

Day one of my second Health & Justice Summit (with Convenzis) was very enjoyable and informative. The title even had me wondering whether I have inadvertantly referred online, or in conversation to the conference as 'Justice & Health'. This one, like January's in Liverpool demonstrates the balancing act that is: health (care) and justice.

Sometimes given the all-encompassing nature of Hodges' model you might think nothing stood out on day one. There is key learning here for me as on Monday I take on a ready-made caseload with an 'Adult' Community Mental Health Team. The team / service designations (Adult / Older Adult) are not mine (but, yes I am part of this 'system') and within teams due attention is given to ageism and 'where' patients are best suited whatever their age. While not specifically prison health, the new part-time role includes references to substance misuse, self-harm, history of violence, personality disorder and post-traumatic stress disorder. (The current political context was also acknowledged and applied on several occasions.)

As I start to write this (25th Nov) PM on BBC Radio 4 is deliberating on violent incidents and the need to toughen up on sentences, the glamourising of certain lifestyles and expectations for life chances, employment, police numbers, youth services, political manifestos, social media and understanding 'all this'. Amid what is a complex background the event's agenda was context packed, but for me several sessions stood out.

Suicide and Self-Harm across the Criminal Justice Pathway
with Dr Louise Robinson

Prison health is a challenging context. The prison health community are not just asking hard questions, they are clearly researching them, as in 'Suicide and Self-Harm across the Criminal Justice Pathway' with Dr Louise Robinson. The research pathway was outlined. Interventions discussed included 'skin camouflage' for self-harm; and Psychodynamic Interpersonal Therapy [PIT].

The development of the study from feasibility to WORSHIP I & "Women Offenders Self Harm Intervention Pilot I":

Walker, T., Shaw, J., Turpin, C., Reid, C., & Abel, K. (2017) The WORSHIP II study: a pilot of psychodynamic interpersonal therapy with women offenders who self-harm, The Journal of Forensic Psychiatry & Psychology, 28:2, 158-171, DOI: 10.1080/14789949.2017.1301529

- through to the latest WORSHIP III. It must be marvellous to be part of evidence-based thought and practice development and with future plans delineated: Complete WORSHIP III, COVER RCT; Cell-Soothe and PrisScope.

Miranda Davies of the Nuffield Trust reported work on "Prisoners' use of hospital services in 2017/18. Many were shocked hearing that 31% prisoners miss out-patient appointments, in contrast to a general did-not-attend - DNA rate of 8.6%. Was this due to the 'patient', or prison reasons? With frequent talk of the need for increased productivity and its neighbours of efficiency and effectiveness: this is painful. Miranda Davies also questioned the limits of hospital data: what (and how) healthcare is provided in prisons; wider aspects of the prison environment; whether researchers are capturing all the activity associated with prisoners from post code alone and coding quality.

Defining trauma

Emma Facer-Irwin explained “The role of trauma and PTSD on negative behaviours among male prisoners: Toward a model of Trauma-Informed Correctional Care in the UK”. When revising and updating - definitions are always welcome.









This definition is useful as on twitter and elsewhere you cannot fail to notice an addition to the debate, critique and vitriol on PTSD with the companion of Complex PTSD.

Differentiating between PTSD and Complex PTSD

This slide 'gave' me the lead for this blog post. It stresses the 'self' and interpersonal difficulties which can create humanistic chaos, by undermining relationships old and new 'in' the Sociological domain. The intra-personal and reflexive aspect is found in the re-experiencing centred on the inter-interpersonal domain as memory, emotional response, dreams (nightmares) and avoidance behaviours that can also affect other people.

In another session the bias, stigma and damage associated with the diagnosis of personality disorder as a 'bin' was noted. This was very positive to hear and later ('elsewhere') on twitter, negative responses in cases of self-harm in casualty by nurses were also called out. I remember this being highlighted in the late 1990s - early 2000s, a surprise that such negative attitudes from mental health professionals can still be expressed and felt.

Here in a tweet are organisers, supporters and sponsors who made the event possible:
https://twitter.com/h2cm/status/1199459402446712832?ref_src=twsrc%5Etfw


More to follow ...

8 Dimensions of Wellness: c/o SAMHSA

The following image the 8 dimensions of wellness was gleaned from the tweet also copied below (media removed). To illustrate the potential scope and application of Hodges' model I have mapped these dimensions to Hodges' model:

8 dimensions of wellness SAMHSA

SELF - individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - POPULATION

Emotional Intellectual	Physical Environment
Social	Occupational Financial

I would place 'Spiritual' outside of the model. This is not an afterthought. The dimensions that are placed within a care (knowledge) domain, this is not to say that there is no overlap. There very clearly is.

As for the 'spiritual' it is outside the 'concrete' structure of the model for the following reasons:

Being outside the basic form of Hodges' model speaks to the universal, subjective-objective, existential, timeless and ethereal qualities that are allied with the 'spiritual'.

SCIENCES: Can the spiritual be proven by science? How often do we experience the spiritual in nature? (I don't know about you but put under the stars and I become a philosopher.) Is the Earth 'alive' in a sense, as in Gaia? Do we imbue Nature with its real value? Being outdoors, in the green literally is currently being emphasised as essential for our mental health.

SOCIAL: Our respective upbringing, culture and social background greatly influences how we individually make sense of the 'spiritual'. Religious beliefs and practices are central to social activities, communities and ethnic groups. As an example of the aforementioned overlap, our social attitudes to ourselves, others with different beliefs are shaped by our social environment.

Central to Hodges' model are the life experiences - within which you will find the health career* - that are shaped by this domain.

INTRA- INTERPERSONAL: What we believe and our motivations are grounded in a person's intellect and emotional state. In this sense an individual can be vulnerable, but an individual's receptiveness to belief and learning can also provide opportunity for recovery as in SAMHSA's

POLITICAL: Whether or not they cite religious doctrine, there are many speeches by true, as in, inspirational, peace-loving, humanistic, environmental rights-led leaders that are experienced in a spiritual manner. It is in this domain that power is exercised and with this the right and freedom to find and practice individual spiritual meaning.

A final thought regards the Spiritual and Hodges' model is that the above also represents the many uncertainties, the incredible mystery and gift of life.

*Hodges' Health Career - Care Domains - Model

My source with thanks:

Brilliant, Brian. #chiefhealthstrategist planting seeds: Social + Economic Factors = Great. Better, All Dimensions Of Wellness + Cross Sector Collaboration = Path to #HealthEquity #8dimensionsofwellness#PublicHealthNurses https://t.co/naowuISmEI pic.twitter.com/YunK0X9PZE

— Lorne Carroll, RN, BSN (@lorne_carroll) May 7, 2019

tête-bêche - "Brother" - for another...

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Brother
... for an-other ...

Purchased 22 June 2018, Waterstones, Oxford, two signed copies

Out Lines

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Source: The Sunday Times, Culture, On Record, 29 October, 2017. p.22.

Article 10 of the European Convention on Human Rights: receive and impart information and ideas

Article 10 of the European Convention on Human Rights provides the right to freedom of expression, subject to certain restrictions that are "in accordance with law" and "necessary in a democratic society". This right includes the freedom to hold opinions, and to receive and impart information and ideas.

“

Article 10 – Freedom of expression 1. Everyone has the right to freedom of expression. This right shall include freedom to hold opinions and to receive and impart information and ideas without interference by public authority and regardless of frontiers. This article shall not prevent States from requiring the licensing of broadcasting, television or cinema enterprises. 2. The exercise of these freedoms, since it carries with it duties and responsibilities, may be subject to such formalities, conditions, restrictions or penalties as are prescribed by law and are necessary in a democratic society, in the interests of national security, territorial integrity or public safety, for the prevention of disorder or crime, for the protection of health or morals, for the protection of the reputation or rights of others, for preventing the disclosure of information received in confidence, or for maintaining the authority and impartiality of the judiciary.

”

Well there is clearly one -

purpose
	Political

- in blogging. Many small voices can make a difference.

It is sobering to realise the responsibility; the responsibility that pertains not only when we receive, but also impart information and ideas. Hodges' model can be concerned with both.

Care is needed when ideas have political weight and a health impact; even though when in the guise of public (mental) health such information and ideas apparently lack inertia. You have to wonder about striking the balance. Forget physics - it's the masses that suffer here.

	physic(s)
sick society

For how many decades have the health professions given the government(s) advice on alcohol?

For how long has the negative influence of advertising on children been questioned?

Always the balance.

So hard to find - like Political balls.

My source (and emphasis): Wikipedia
http://en.wikipedia.org/wiki/Article_10_of_the_European_Convention_on_Human_Rights

CARE: Whether NHS or Social Care ...

C	A
R	E

Whether -
NHS or Social Care^*
what
C.A.R.E.
is crying out for is a
universal, shared, holistic and wholly integral conceptual framework.
Then and only then will the currencies^# of care be
transferable, translatable and transforming!

* Private, 3rd sector, religious order, or social enterprise ...
# Currencies does not just refer to finance.

h2cm - Being at the center of things [I]

The center of Hodges' model can represent many things:

an epistemological nexus for the transdisciplinary dependencies of our times
multidisciplinary coffee shop
self-care engagement stage
the chaos of all things
holistic harmony
integrated idyll*

More down to Earth and acknowledging this cruciform '+' structure as a mythic device, in addition to searching for the mysteries of the universe at the center we can also place the 'well' person there.

As the previous post on ADLs suggests the 'well' person can function on a basic level and has negotiated the four axes and the four and five fold knowledge domains. They can therefore be considered (sufficiently) wholly integrated. We are all travellers, constantly traversing these domains of experience consciously, unconsciously, expertly or with the awkwardness that denotes the novice.

Conversely and reflecting the model's utility: it is also possible to locate the unwell individual in the center too. In this instance the placement suggests impoverishment of experience, ongoing personal and social stasis and in the case of substance misuse the presence of specific disruptive focus and preoccupations. The person becomes lost to their potential, stuck in a 4:5-fold minima. They continue to travel chronologically, but the journey is spiral, self-iterative and diminishing by return.

However: what you can see you can change, or come to terms with.

*from Greek eidyllion, little picture (h2cm as a snapshot).

Original image source: http://www1.lsbu.ac.uk/water/protein2.html

Simply the best... 4-Domains Pale Ale!

Drugs and alcohol
have permeated
our various cultures and
civilization for millennia.

Our models of health and social care should reflect this. ...

More to follow on drugs, dementia and the Berlin Wall.
I just had to get this out of my system ...

Image sources:

http://www.hbclark.co.uk/clarks-brewery.html
http://www.wordforwine.co.uk/jwlees/index.php
http://www.woodmoorbeer.org/Pages/Snordog_Kenya_Labels.html

Drugs, Policy and spent Energy

The ongoing controversy here in the UK over drugs policy amid the sacking of Prof. David Nutt - chairman of the Advisory Council on the Misuse of Drugs and since Friday the resignation of other members highlights the tension between the SCIENCES and POLITICS.

As a father, mental health nurse (and light imbiber of real ale and wine) all I know is that the government has been lobbied for decades by concerned groups over the risks of excessive alcohol consumption. With changes in alcohol licensing opening hours and pricing/tax it seems the government has the local town centres and community legislation it deserves.

Given the current spat you might think that within Hodges' model the SCIENCES and POLITICAL domains would be diametrically opposed? But no! There they are bosom buddies on the mechanistic side of the model.

Although the clue is in the title - advisory - as to the extent to which the government is bound to follow advice, the government's policy, advisory groups and policy should be in accord as far as the media and public are concerned.

Otherwise what price for evidence-based politics?

For individuals and communities alike we need order between the SCIENCES and POLITICS otherwise chaos reigns. Order does not just fall out of the tree. The issues here include at risk youngster's for whom exposure to cannabis might precipitate a psychotic episode; the granularity of a classification of drugs for legal purposes and that for clinical and social care. The debate is complex and takes work and energy on many levels. There are many dimensions to appreciate in this situation:


While very unfortunate, this is timely as I read Ben Goldacre's Bad Science.

You do have to worry about the position of
common sense.

There are other sources of heat already on the boil with many spillages to follow. These will arise from the friction of SCIENCE, climate change and policy. Ah bliss to live in interesting times. ...