Tuesday, August 8, 2017

Improving Westerosi Maternity Services - Every Mummer Counts

The long awaited follow up to my argument in favour of improved Trauma Services is looking at the need for better maternity care in Westeros.

Women in Westeros get a bad deal and is this most evident in it's shocking maternal mortality rates. Whilst definitive statistics are difficult to come by there is a rich stock of qualitative data from documentary series "Game of Thrones". It shows that childbirth is dangerous and pregnancy gives no reprieve from the violence of the world.

The first major problem is access to basic medical care for even the most highborn of women. Arguably the root of Robert's Rebellion was the fact Lyanna Stark, though surrounded by willing servants in a prestigious tower died from a post partum haemorrhage. Adequate access to uterotonic medication and availability of those suitably trained in repair of perineal trauma may have averted such a tumultuous period in Westerosi history. The stigma for survivors is also a burden to be borne. Tyrion Lannister born without access to pre-natal USS screening to actively manage the pregnancy led not only to Joanna Lannister's death but also a lifetime of scorn from his remaining family.

It is no better across the Narrow Sea where perinatal mortality is also worryingly high. Added to this we have proof of non evidence based blood magic from unlicensed Maeges have been responsible for the stillbirth of Daenerys Targaryen's child. It is important that any new process or therapy is rigorously peer approved and based on sound scientific evidence and the risks of alternative therapies are communicated to women and consent gained accordingly.

The stories here are just the affluent tip of the iceberg. There will be thousands of stories of less privileged women dying in poverty due to lack of access to midwifery care and sanitation.

That's not to say there aren't successes. There is documentation of multiple births north of the wall at Craster's Keep and indeed the Queen on the Iron Throne has successfully delivered 3 children under dubious lineage. Consanguinity as a protective factor could be an interesting topic for further research?

Maternal Mortality statistics also contain deaths from indirect causes, which commonly seems to be deaths from domestic violence. This includes the recent death of Walda Bolton and her newborn son. Having successfully traversed a high risk pregnancy with a raised BMI, care in post partum time should include a thorough domestic violence risk assessment which would have surely have picked up on the dangerous individuals in her household. Without robust systems and social services in place these vulnerable people were let down by the crown.

Calls are then made for access to those with formal training in childbirth and maternity care. This surely must fall into the remit of Maesters who are ideally placed to lead maternity care. They have anatomical and pharmaceutical knowledge to make a real difference in the delivery of maternity care. However they have their own issues before being made part of the maternal health team. Being very secretive with their knowledge is not the right way to go about healthcare innovation and they would need to embrace a more open non-blame culture in improving outcomes. They would also need to evaluate their own practices against current trends to ensure that Maesterising birth doesn't lead to poor outcomes and a loss of maternal choice in their birth decision making. Lastly, for too long women's decisions are being taken by men so the archaic bar to women joining the Citadel must be reversed in order to allow women to care for women and be armed with as much up to date information as possible.

There is reason for cautious optimism with a woman on the Iron Throne women at the head of many powerful families currently, the time is right to allow the establishment of midwifery as a right for every pregnant woman in Westeros. Couple that with access to evidenced based maester led high risk care. What good is war if there is nobody to carry on the family lineage? Allocation of recently acquired gold would go some way to show the people that women's health is taken seriously by the current administration.

Wednesday, June 14, 2017

Election Dissection: This time it's Personal

2017 General Election represented my first foray into national electoral politics. I had stood as a paper council candidate for the Green Party in the 2017 local elections but this was obviously a much bigger deal. I have written about how the Green Party did nationally here but also wanted to look at my own performance and plans for the future.

When people ask how on earth did I get into this, there was no magic moment, just a series of small events which lead to standing for Parliament in my home town. In 2015 when I moved back to Northampton, I had voted for Green Party at the 2 previous elections and decided in that summer I wanted to get more involved with local politics, seeing as my knees were no longer up to Sunday league football. So I joined the Green Party and attended the September 2015 Party Conference, which was fantastic, but due to work, didn't manage to make it to any meetings that year. Then in 2016 I attended an event protesting against an incinerator being built in the town with support from Northants Green Party. It was here I met local activists and resolved to attend meetings to see where I could help.

After a couple of meetings we had our AGM where the chance to run social media and website came up, which I took up in September 2016. We then organised attending events and marches for the NHS, Pro-Democracy and Anti-War causes as well as local air quality testing. I was asked to be a paper candidate in the 2017 local elections, which just provided a chance to vote Green in my area. There was no campaign, although I did help out with the campaign for our target ward in Northampton. Then the snap election was called, and despite having selected 7 candidates back in 2016 on the hunch a snap election would be called after Brexit, we had 3 vacancies for General Election Candidates in Northamptonshire. I expressed an interest, made a short speech at our selection meeting and there I was!

So, what happened next?

Election was called on 18th April, I was selected on 2nd May, attended local election count on 5th May and submitted my application to local electoral services on May 10th, having not managed to agree any Progressive Alliance locally. I had put up the £500 deposit from combined party, crowdfunded and personal funds there was not much time or money to run a large campaign. This not being helped by continuing to work my full hospital commitments.

I set up a Facebook campaign page and churned out tweets, videos and updates. I answered hundreds of lobbying emails and pledges to support various causes. I went on as much media as I could manage, radio, TV, newspaper hustings. I visited my old school and supported national campaigns. I posted about 5000 leaflets with the help of a number of local volunteers, who I am massively grateful to.

Now, regular readers of my blog will know that if somebody were to ask me what my biggest weakness was, I'd say "Job interviews". I'd just signed up for a public job interview which will last 4 weeks. So, way to face up to them fears!

I think that I honestly put about as much into the campaign as I could. I'm not happy with the outcome and some of that is due to a national trend of a reduction in Green vote and rise of an actual Left wing Labour party. Part of it I think was due to my limitations as a candidate, not only financially but with free time and getting my message out. I was aware that we needed a distinct message from the Labour Party but unfortunately too many of my answers at hustings began "I agree with Kevin...". My family and friends were a great help but I didn't want to put too much on them in terms of door knocking and leafleting so much of that I took on myself. We didn't have an army of door knockers or reams of canvassing data. I didn't feel I had the money to put out a full free post leaflet to every constituent and unfortunately did hear murmurs that some people didn't know a Green candidate was standing. I was also a bit miffed that media outlets like ITV news would interview the other 4 candidates but not me, especially as in terms of votes, 3 of the 5 of us were fairly close.

I know you should never watch yourself give media performances but I looked hesitant and nervous about putting a point across which was usually a good point! The hesitancy is me though. It's who I am. I run everything I think through a filter as I'm worried what people would think when it comes out. When I'm tired or stressed sometimes the filter doesn't work! At least I can say that all of my media performances were authentic and not somebody else. I think I got better as I got more into it, but with only 4 weeks there wasn't much time to warm up.

So, what happens next?

Firstly, it's my annual appraisal later this month (ARCP) which decides if I've progressed enough this year as a doctor to be allowed to go onto the next stage of specialist training. There are still some things to tidy up from there and work to be done.

As for the Green Party, we've got a lot of thinking and work to do. It's clear by our vote share that our message wasn't getting out or convincing enough. The Green policies I like the most are the ones we don't share with Labour: Citizen's income, Nuclear Disarmament, Soft Brexit, Proportional Representation and commitment to leaving fossil fuels in the ground. However these weren't what the election was about. Corbyn shut Brexit off as an issue by essentially agreeing with the government and the important issues of the electorate: - Social care, Education and the NHS we didn't offer an alternative to Labour policy.

What I want to do next is figure out how we can do better next time, given our limited human and financial resources. Personally, I enjoyed the whole thing and would thoroughly like to do it again. I just don't like losing so hard. The Green Party target to win policy I think is the way forward. As a local party with maybe 2 dozen active members, for the 2019 local elections, I think instead of running many campaigns in a low power way, perhaps we need to focus our attention in 1 area to get maximum gain. That would mean me volunteering by leafleting and door knocking in one place with ALL the other candidates and members in just one or two wards.

I'd also have to change the type of work. Seeing the 2 main parties campaigning  threw into sharp relief the size our tasks. They proved that you need boots on the ground not only to leaflet but to door knock and get canvassing information. That is something we could be doing all year round, and will try to attend a Green Party canvasser course in the near future. If we have 5% of the activists we need to focus our efforts in a smaller area to make a gain. Even a single council seat in Northamptonshire would be a huge improvement not only for ourselves, but for the voices of locals who see a sea of blue through all the diesel fumes.

We are at our  best when we are local, visible and vocal, which with regards to air quality I think we are. I think we ought to champion this issue across the board for all of our active local measures and direct efforts to getting more air testing data, more time at council meetings and more local support. We could start a "Green Business" group, to promote businesses which have an environmental angle or do something good in the community, which could  hopefully attract business and sponsorship. Every chance to get in local media to show we are doing something, whether that is fitting new air tubes, picking up litter or turning up en masse to cabinet meetings.

Personally, I could get more involved with my hospital and community groups to help with issues we might be facing. My current role as BMA rep it appears that our major issue is parking. Campaigning on something to address this like a park and ride for example could be the way forward. In my own ward, I want to be attending parish council meetings and trying to figure out what is happening with development (or lack thereof) of the St Crispin's Hospital site which has lay derelict for the 2 years I've lived there. I'll be putting these ideas to our post election meeting tomorrow, so I could end up doing a lot of work whilst continuing my O&G training, which as my sole income and life for the last 13 years is no small priority.

I think there is still a future for the Green's, we just have a grab it work harder for it and make each Green activist count double with the work we put in!

Sunday, June 11, 2017

Election Dissection

The first general election of 2017 was one where everyone lost.

Theresa May is terminally damaged by arrogantly calling an election on the issue she wanted, Brexit. Whereas the electorate rightly voted about policies, where the Tory manifesto was found wanting. Her leadership proved to be anything but strong and stable, and she's going to limp along with the help of some climate change denying bigots.

Labour lost this election, just not as badly as everyone thought they would. They are over 60 seats short of forming a majority government, despite gaining seats in key marginals. Corbyn may have grown as a leader and won some young voters, but will the legion of no confidence voting MPs suddenly have discovered a love for him? Against all odds Labour appeared to have won some seats, have they got it in them to do it again later this year?

The Liberal Democrat land grab of the remainers didn't bear the fruits first thought and the echo of their Europhile drumbeat will ebb away as Brexit negotiations continue. Even strong remainers like myself, just want to see it done with in a quick and painless a manner as possible. Delaying things will just put on hold the fact that we need to remake our country in a fairer way and sort out our environment and public services.

UKIP may have fell away considerably, but their supporters didn't exclusively flood to the Tories. Again, once Brexit is over what is there for them to campaign on? I imagine they will adopt more right wing, anti-immigration dog whistle politics to differentiate themselves from the Tories.

SNP having hit a zenith last time out, were never going to do that well again. The issue of Scottish independence spooked people into voting Tory in Scotland for the first time in my lifetime. I think they have about hit their mark with vote share and seat number.

As for us, The Green Party didn't do well even by our own measurements. Sure, Caroline Lucas was returned with an increased majority and we got half a million votes nationally. Our aim was 2 MPs which we didn't seem anywhere near getting in our key targets of IoW, Bristol West & Sheffield Central. We also only got half the votes we did last time out. The reasons for this I think are the lurch to the left of the labour party where there was significant crossover with policies we've held for a long time such as scrapping Tuition Fees and renationalising the railways. This meant people who joined the Greens because there wasn't a progressive left wing party around any more felt comfortable to go back to labour. Also a small party with a campaign short on resources and canvassing data was never going to perform as well as during a normal electoral cycle.

We also have an issue with the Progressive Alliance policy. I can see why we do it in that we are a smaller party and would rather have a labour government than a Tory one; but I'd rather have a Green one than a Labour one! We unilaterally stood down in seats as a show of good will hoping others would see it's benefit and it wasn't reciprocated. It won't be reciprocated, that much is clear. Any sign of Labour doing deals with us, overtly or covertly will be seized upon as weakness by the press and or Tories. It seems any co-operation we do is expected across the board.

Personally, the only online grief I received for standing for parliament were from Labour supporters who thought I shouldn't be standing. Not once did they try and tell me about how great their policies were or why we should vote for labour, just "waste your vote on Green" "A green vote is a Tory vote". You win votes by having better policies, not bullying smaller parties into oblivion. We are very different to the Labour party, they've moved their policies towards us, not the other way around. We don't want to fund nuclear war or go ahead with leaving the single market or continue with environmental inertia. I also think, many of our remaining voters wouldn't automatically go to labour. I think many would abstain or spoil if we aren't on the ballot, as many vote Green as they are disillusioned with mainstream electoral politics.

The way I see it, we have 4 options nationally going forward and none of them are perfect. The current half measure hasn't worked, I can't see the status quo happening again where we do all the stepping down and get very little in return. I also wouldn't want to do what a couple of friends of mine in Momentum would like, which is to become the Environmental wing of the labour party and trade our identity and policies in for a few former Greens getting Labour seats.
We could double down on Progressive Alliance, formally support Labour where we don't stand and stand down in 100s of seats. Not only to stop a "split the vote" situation where we lose 100s of deposits but to focus national resource at getting more Green MPs in places they might actually get elected. This might get us another MP and a chance to push proportional representation, but risks alienating Green's nationally. Or we abandon the notion all together, stand wherever we can and show voters that we offer a different vision to all of the mainstream political parties and be proud to do so. This might get us a wider reception but would probably keep our vote share in the low single figures range.

The elephant in the room is the First Past the Post electoral system. It's defenders say it keeps out extremists and provides decisive government. On evidence of the most recent election, it has done neither. The other defence of FPTP is that it maintains a local link to your MP. In the seat I stood in, the address of the new MP on the ballot is 60 miles away. Democracy doesn't work if large quantities of people's vote just don't matter and for 500,000 people we get 1/650th of the voice in parliament. All efforts in cross party co-operation must have proportional representation at it's heart. I'm not sure which way we Greens should turn next with regard to PA, but it needs to have change the entire voting system at it's heart.

The FT have done some excellent graphs about changing demographics and voting trends. I recommend you give it a read!


Monday, January 2, 2017

A Difficult Conversation

I didn't make a new year's resolution this year. Mostly because any previous ones I've made, go out the window within a couple of hours. Also, my go to "stop being fat" resolution is already being attempted as I've been on a "healthy eating" kick for 5 months or so already. However if I were to make a resolution, other than blogging more, it would be to spend my free evenings not on social media but reading the increasing pile of books I have accrued over the last few years. The pile ever increases because whilst I buy around a book a month with good intentions, I probably only get through 1 every 2-3 months. There are currently a range of biographies, GoT novels, political polemics and other books building up on my bookshelf. I'm so terrible at keeping up with it that I purchased Paul Mason's "post capitalism" twice as I forgot it was already in my "to read" pile. I guess that illustrates the inherent waste of consumerism he is trying to get at; I don't know, I haven't read it yet!

Anyhow, I started as I meant to go on and picked up Atul Gawande's "Being Mortal". I thought this was a safe place to start as his other book I read "The Checklist  Manifesto" was so good it changed the way I worked in the operating theatre. Going from sighing my way through the WHO checklist to making it a central part of being in theatre. Gawande is one of those people who seems to be able to do anything. An accomplished surgeon, writer, NGO and public health leader. In fact if he played for United he'd be the picture at the bottom of this blog!

Its about how medicine has changed the way we experience ageing and death and the things people around America are doing to try and improve this situation. He tells a story of not wanting to confront a young patient's impending death from lung cancer by using euphemisms, and how difficult it was to actually bring up the subject for the doctor. Instead talking about "putting this issue aside so we can focus on the lung cancer". This resonated so much with my own experience of  these conversations and I had an example where I ended up having a difficult conversation, in a situation you wouldn't normally expect.

The junior doctors usually have the job of clerking in elective patients for day case procedures. Usually it's a quick chat, write up their regular medication and make sure their consent form and blood tests are up to date. This case was unfortunately a young patient with advanced ovarian cancer coming in for an ascitic drain to relieve the discomfort of having fluid build up in her abdomen. Her cancer was incurable and she had tried 2 types of chemotherapy without success already.

I duly went through her medical history and medications, which were surprisingly few for someone so poorly and noticed she was on a statin. A statin is a drug that lowers cholesterol and can help prevent strokes and heart attacks if given to enough people over a long enough time period. The patient told me that they gave her nausea but stuck with a low dose because it was good for her in the long term. This is right, but things had changed since she started on her cancer journey.

The easy thing to do would be chart the statin and get on with things but I asked if she wanted to carry on taking the medication. I struggled to find a way to say "why take a drug that makes you feel ill and won't help you because you'll be dead from your cancer before you get the benefit of the statin" without sounding horrible. So I tried to see what her understanding was about statins, and she seemed clued up and then seemed to stop and then was to the point for me:

"The cancer will get me before a heart attack will, won't it?"

I gave a non-comittal grimace and suggested she could stop it to see if it helped her nausea. She stopped the drug and when she came back a few weeks later for another drainage, she told me she felt slightly better from a nausea point of view. It showed that having difficult conversations are actually be worth it for patients and we as doctors tend to practice with inertia (especially if another doctor started the medications). Helping patients make sensible decisions about preventative medications is a small part to play, but showed tackling these may help in the long run.

So, just like the Checklist Manifesto changed my operating pratice,  it looks like Gawande's next book will change how I practise medicine in patients who are terminally ill.

Oh, and if anyone wants a copy of Paul Mason's Post Capitalism, I have a spare!