Tag: sociology nursing social context

The personal is political; care in an age of spectacle.

Are we really surprised that the BBC’s  Panorama has again uncovered  poor quality care and abuse in a home for older people?

We know the roots of this, and I have previously argued that this is a political game. This is also personal because, and this point has been made many times  before, I will be old one day and may well require care. Therefore I do not want to be treated like sh*t as a resident on the Panorama  film stated. It happens because the care sector is undervalued, invisible, ‘women’s work’ and it is thought by some  that it can be done by those with little training, poor supervision, risible pay, poor patient ratios, no professional development and inadequate management.

Individuals will of course be blamed and sacked citing ‘accountability’ as if it is the holy grail of quality care and patient safety.

What to do? The first is to recognise that this personal trouble is a political issue and nurses are front line staff in the trenches. In the UK for far too long nurses have been reluctant to use union power to address these fundamental issues. Yet, just when we need it, union membership across all employment sectors have dropped as workforces became more docile in the face of deregulated labour markets. Faced with the ‘flexibility’ requirements demanded by employers, resulting in the growth of zero hours contracts, part time working, minimum wages as targets rather than base lines, workers have become more pliable generally. Nursing, being a gendered occupation with its emphasis on self sacrifice and care, has historically shied away from exercising any worker power while simultaneously picking up the crumbs from the medics table (doing their ‘skilled’ tasks for nowhere near the pay) and now bowing to the control of their work as dictated by management.

In California, in the US, nurses are joining Unions and have a staffing ratio law of 5:1 for med/surg, 2:1 for ICU, and Psych 6:1 meaning five patients with 1 nurse. CA AB394 came about by the CA Nurses Association to implement their RN Staffing Ratio Law. William Whetstone (Professor of Nursing California State University)  states “Staff nurses were sick and tired of being abused, putting up with crappy workloads, incompetent nurse administrators and managers, and on and on. I can remember when I did staff nursing dealing with a patient load of 10 to 12 patients with no thought to their acuity. As a result, CA became the first state through the effort of the CA Nurses Association to establish RN-to-patient ratios. The law was successfully implemented January 1, 2004”.

Is this an increasing phenomenon? Are we finally seeing a backlash against the dominant political hegemony that does not want to pay for care? We can study this until forever, but that fact remains – care costs. It costs a lot, requires skill and adequate ratios.

In California it seems nurses have had enough, got organised and agitated for change. They have looked beyond the representations of nurses as caring angels and seen themselves as the exploited.  They have plucked the imaginary flowers from their chains and acted.

Consumer capitalism would not want this happen because care is seen, in this context, as a cost to be born not by society but by individuals and families. Consumer capitalism instead wants to fill our heads with distractions and representations using the ‘spectacle’.

News and other media constantly feed us representations of the world that actually do not exist; they are constructed for news and or as entertainment. Panorama falls into that trap because it represents poor care in a particular way and is unable to drill down to the root causes. The TV itself is a medium of the representation of actuality and can lull us in to classifying the poor care we see as almost entertainment; the lines between truth and  fantasy become blurred.

 

“In societies where modern conditions of production prevail, life is presented as an immense accumulation of spectacles. Everything that was directly lived has receded into a representation” (Debord 1967).

Consumer capitalism has ripped the citizen role from the heart of nursing and replaced it with consumerism in which we are presented daily with ‘the spectacle’ – representations of reality that are without form or substance but which service to make sacred the profane. The spectacle specifically aimed at women include the array of women’s magazines which preach that you can never too thin or that your breasts require surgical enhancement; thus are we distracted about what is truly real by a false representation, within care employment contexts that are precarious, undervalued and invisible. Feminists know this, critical theorists know this, those with a sociological imagination know this, many women actually feel the cognitive dissonace that this engenders. In California,  nurses have acted as citizens, able to see pass the distractions for long enough to see exploitation as it really is. In the UK those nurses who can see the reality, need to the support to take charge of care in this country.

Ordinary citizens need to organise their frustrations and anger over health and social care and cohere into a viable opposition. Unfortunately UKIP are currently presenting another false representation with the spectacle of Nigel Farage presented as an ‘ordinary bloke’ that nearly 30% of the electorate are falling for.

We saw a spectacle of poor care again last night, lets not allow it to become entertainment for its shock value, lets instead urge action by all of us to provide the care older people deserve.

 

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 

 

Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.

 

An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.

 

The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.

 

According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).

 

If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.

 

“Let each person tell the truth from their own experience.”  Florence Nightingale.

 

Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.

 

The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.

 

“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.

 

There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.

 

Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.

 

“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.

 

Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.

 

A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 

 

“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.

 

Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 

 

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!

 

It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.

 

Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

Care Quality in the NHS. We can do better than this.

Care Quality in the NHS. We can do better than this.

 

Just published: a research study into culture and behaviour in the NHS. Dixon-Woods et al (2013) undertook a mixed method study from multiple sources using surveys, ethnographic data, board minutes, publicly available data sets and interviews. The reasons for doing this of course are well known post Francis and Keogh. So what did they find?

 

“an almost universal desire to provide the best quality of care…bright spots of excellence…but considerable inconsistency”.

 

The reasons put forward will resonate to many interested in quality and management issues in the NHS. Nonetheless it is useful to have some empirical data to support what we think we already know. Working against the desire to provide high quality care are the usual suspects:

 

1. Unclear goals

2. Overlapping priorities that distracted attention.

3. Too many external regulators

4. Poor information systems

5. Variable management and staff support

 

They concluded “…put the patient at the centre…get smart intelligence, focus on improving organisational systems, nurture care cultures by ensuring staff feel valued, respected, engaged and supported”. This last sounds like Roy Lilley’s oft quoted ‘fund the front line, make it fun to work there…’

 

Where does one start with this little list? First…get those pockets of excellence out in the light, let everyone see exactly how some are getting it right. Network, share, talk!

 

There are many intelligent people in the NHS, some of the staff are the cream of the educational system and others, what they lack in super cognitive functions, they more than make up for in commitment and care. What is lacking is the organisational foundations to harness this.

 

Nurses tell me that they have little or no time for professional development, clinical supervision or networking because they fill their time with giving care. They are already ‘putting the patient first’ but they lack ‘smart intelligence’, i.e. data that tells them that care is good or poor. Instead they are bombarded by other data that provides managerial information but little in the way of the patient’s actual experience. My blind uncle’s cup of tea being placed on the other side of his bed out of reach and with no verbal communication to tell him it was there, is a bit of data that does not get fed back to anyone. The RN’s need to be able to know if poorly trained staff require performance management. They need an ‘organisational system’ that allows the supervision and training of support staff that they oversee so that cold cups of tea are not left bedside.

 

 

Managers need to give more than lip service to making staff feel valued, respected, engaged and supported. And that is the crux, because Trusts chasing other organisational goals are liable to take their eye of this particular ball, measure success in terms that do not relate to the care experience and are liable oversee a culture in which staff become disengaged, disillusioned, distracted and demoralised.

 

The issue is of course wider than Trust and NHS management. It is about the value society is willing to place upon care, and thus how society structures itself to provide that care. Are we then asking too much of Trust managers?

 

It is of course the case that the vast majority of care is done outside the NHS most often by family, most often by women. This of course applies to both health and social care. This is the socio-political context in which the NHS has to work, picking up the pieces when care cannot be given by this informal unpaid army. The NHS can intervene magnificently when that care need is medical or surgical, but it just was not designed for the sheer number of frail elderly people requiring some form of care. Neither is society now structured to cope.

 

Social and geographical mobility that fragment communities and families; different societal and individual expectations; the changing demographic of an ageing population; longevity and medical advances that keep us alive but also result in many more experiencing chronic illness that requires supervision and care; the unglamorous nature of care; the still gendered nature of care; the structure of financial penalties for leaving the job market or career ladder to look after ‘mum’; the structure of rewards that channels money into socially useless bullshit jobs; the structure of rewards that sees prizes, fame, medals, celebrity heaped upon narrowly talented non entities too often still just out of nappies; the ability of the feral elite to ferret the lion’s share of the nations’ wealth into offshore tax havens; a government that sees public service and the public sector as dirty words; a government that is leaving it to the market to sort out, an education system working for the minority while the majority compete against each other in a rigged system; a job market increasingly characterised by an increase in low skilled, part time, low waged employment; a private sector that will not rightly touch getting involved in care, a risk averse managerialist, bureaucratic and financial accounting approach to care…

 

In short, care costs, but the costs are externalised onto those who too often are unable to pay. We have increasingly individualised the risks and costs arguing that health and social care cannot be afforded by the state, especially now in times of ‘austerity’. The State is not the same thing as society but society needs some organising structure to put its values into action. We have left the values of individualism and market freedom blind us to the changing nature of society and the care pressures that come with it. We are now ill equipped in many areas to provide the context for high quality care.

 

A question then can be raised about whether the bright spots of excellence exist despite the overall socio-political context? Could the NHS better foster those bright spots if its supporting context was different?

 

NHS is not just about Trust management, it is also about society having a different vision.

 

 

 

 

 

 

An impact of male gender on the experience of illness

An impact of male gender on the experience of illness

 

CECIL R., McCAUGHAN E., and  PARAHOO, K. (2010) ‘It’s hard to take because I am a man’s man’: an ethnographic exploration of cancer and masculinity European Journal of Cancer Care 19, 501–509 

This paper reports on a study into male participation in cancer support groups, which elicited data on the impact of cancer on masculinities. This small qualitative pilot study, which took place in Belfast in Northern Ireland, involved semi-structured interviews with eight men with a history of cancer who were no longer being actively treated (i.e. they were not receiving chemotherapy or radiotherapy), and who were proficient in spoken

and written English. Whereas most studies into men with cancer that have looked at issues of masculinity have been on prostate and/or testicular cancer and have tended to focus upon sexual ability and activity, this study identified more sociological issues of concern that also present challenges to masculinity and to male identity.

 

Economic concerns were identified as being major issues for men, as were their changing role vis-à-vis their family, friends and colleagues, and changes to their body and to their body image.

 

The findings from this study indicate that cancer support services need to be gender sensitive in order to ensure that interventions do not undermine masculine values but address men’s concerns and foster their positive coping strategies.

 

 

 

Masculinities (and Femininities).

 

The above research indicates what being a man is and what values are held by men in Northern Ireland. Three issues seem pertinent for these men surviving cancer:

 

  • Money worries, perhaps the role of ‘breadwinner’ is undermined.
  • Their other roles in life and how cancer changes that.
  • Body image – virility and strength might be challenged.

 

These are the subjective experiences of this group of men, so that we can see that cancer not only brings about physical changes but also challenges the very idea of what it is to be a man. Are these men feeling a loss of control and power over their jobs, their lives and their women? In the context of testicular and prostate cancer the idea may be that loss of sexual function or perceived loss diminishes them both in their own eyes and in the eyes of wives and girlfriends.

 

But, what do we think being masculine actually means for other men? Are these ideas fixed in society?  Raewyn Connell discusses what being masculine means and considers that it is a dynamic concept, i.e. what it means to be a man is not fixed and can change over time and across a society. Masculinity is about where one sits in a power structure, and therefore there is more than one masculinity. So we must be careful to understand that a change in health status may be subjectively different for the metrosexual man, for example living in central London. Connell also refers to a ‘world gender order in which men continue to have power over women’.  A cancer diagnosis for a man will of course impact on his family and partner and if they are feeling challenged in the most fundamental aspect of their identity this may well impact on their on-going relationships. We might ask whether we have a set of norms and patterns for the ‘correct’ social response to these challenging issues.

 

The research paper suggests that those working with men diagnosed and treated for cancer might want to think about the values men hold , and clarifying with them their coping strategies. It clearly illustrates the psycho-social nature of a condition like cancer. A question remains though around how well equipped nurses feel they are in relation to these issues, is it easier to stick to bio-medical issues around treatment modalities, prognosis and coordinating support services.

 

Rabin (2009) also reported a US study which suggested:  “Men who strongly endorsed old-school notions of masculinity — believing the ideal man is the strong, silent type who does not complain about pain — were only half as likely as other men to seek preventive health care, like an annual physical”. This then suggest that how men  see and feel about themselves in this manner are putting themselves at risk of for example a too late diagnosis of cancer or other serious conditions such as hypertension.

 

This anonymous post form the US raises the issue of obesity, ethnicity and class in the relationship between men and their doctors, arguing that condescension, arrogance and rudeness on behalf of some doctors may also be class and racially based:

 

“The problem is, a LOT of doctors are rude, condescending assholes who may be very good scientists and diagnosticians, but are HORRIBLE at customer service!


For a lot of men – including myself – going to a 12:15 appointment but not being seen until 2 and then being told a whole lot of stuff that I already know AND having to deal with medical arrogance is insufferable!

 

At this point he is illustrating issues around access to health services – this relates to wider social structures around employment patterns for both men and women who now make up > 50% of the UK workforce, so access issues may not be gender specific but might have socio-economic foundations. In other words people on low incomes with less freedom to leave work during the day might put off going to the doctor unless they really have to. Consider the man with prostate issues or testicular lumps which might not be painful who then does not go to the doctor because of losing a day’s pay. This applies to those who have been labelled the ‘precariat’.


Add to that that I’m fat, African American and working class and multiply the rudeness factor x 20.  I know I’m going to be accused of being a fat pig and a glutton and will be branded as a liar if I comment on what I eat – I know the doctor won’t give a damn if I give him/her an accurate description of how I got fat in the first place – and I know that I will be blamed, guilt tripped, shamed and not listened to – why would I want to subject myself to that bullshit (AND have to pay a $ 20 co pay!)


If I want to be insulted for being fat, I can find some neighborhood elementary school kids who will do it for free!

 

Here he illustrates obesity as a ‘fatphobia’, or obesity as a personal moral failing which might be the default position of some healthcare professionals. The responsibility deal initiated by Andrew Lansley emphasises taking personal responsibility for health and seeking partners to do so. Being fat could be seen as not taking that responsibility. This view downplays or challenges the idea of an obesogenic environment. It buys into the cultural/behavioural explanation for health, i.e. that illness arises because of the your cultural habits and behaviours (eating junk food and smoking for example) and it also form part of the Moral Underclass discourse which focus on the failings of people themselves and locates the origins of illness in their ignorance and fecklessness.


Like a lot of men, I would NEVER tolerate that kind of rudeness in any other type of social setting, so why would I put up with it from some douchebag wearing a white lab coat?


I suspect women are socialized to tolerate much higher levels of disrespect and verbal abuse than men are – which might explain why they have a higher tolerance level for the verbal and psychological abuse that many doctors inflict on their patients.


They’d have to – because, from what women have told me, female medical exams are not only filled with insults and rudeness but procedures that are actually physically painful (like the mammogram and the speculum).


So, if doctors want male patients to come to get routine checkups, they need to learn how to talk to their patents with courtesy and respect – especially their fat patients, who need more medical monitoring than our skinny counterparts, but are more likely to avoid the doctor’s office because of all the bullshit that many doctors put their patients through.


The same goes with African Americans – we get a double dose of condescension and rudeness, get less pain management and in general get worse medical care than our White counterparts.


I actually had a White doctor at Columbia Presbyterian Hospital accuse me of “fraud” when i came to have a knee injury treated – and he also ordered me to “go to the clinic across the street, where the neighborhood people go” (that is, CPMC’s medicaid clinic, who’s patient load is almost entirely Black and Latino, as opposed to the clinics at CPMC, that treat affluent White patients from other neighborhoods).


In short, it’s not a “masculinity” problem – it’s a medical rudeness problem – and men
are just more likely to avoid doctors to get away from the rudeness and verbal abuse!”

 

 

 

 

 

Here we have an illustration of intersectionality, i.e. how class, ethnicity and gender interact to position a person in the social hierarchy and how this then affects health.

 

So, being a man in a particular subculture can be dangerous: you take risks occupationally which you  might not be able to avoid , for example in the construction industry, and you take risks with lifestyle choices because that upholds your idea of masculinity. Not going to the doctor because a) they are a different class and b) ‘that’s not what mend do’ and c) you cannot afford the time or money further places you into a place of risk of undetected health problems. However, gender is only one aspect of health seeking behaviour, morbidly and mortality patterns. Arguably low socio-economic status is  more important in explaining health inequalities.

 

 

 

See also:

 

Stets, J., and Burke, P. Femininity/Masculinity in Edgar F. Borgatta and Rhonda J. V. Montgomery (Eds.), (2000) Encyclopedia of Sociology, Revised Edition. New York: Macmillan. pp. 997-1005

An unachievable utopia in nursing practice? Utopia will not be paid for by the ‘Greedy Bastards’

The Politics of Nursing: Care is expensive: get used to it.  

Introduction

By now many nurses will be feeling a mixture of despair and insult they have received following the many reports into poor quality care. These feelings can lead to disenchantment, disengagement and disillusionment with both politics and health care delivery. Jane Salvage (1985) suggested that nurses ‘wake up and get out from under’ and while recognising that for some this past entreaty to engage politically may further entrench those feelings, the need for nurses and nursing to do so has not diminished. As Stuckler and Basu (2010) argue, government policy becomes a matter of life and death as ‘Austerity is killing people’. Nurses are part of the front line in promoting health and caring for those who are ill or living with chronic conditions. Their work is therefore framed by politics and political decisions. The bottom line is that there is a ‘bottom line’ to care, societies prioritise resources depending on their values, however there is not a level playing field in this regard. Care is under resourced, undervalued and often invisible. As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care Nursing must ally itself with the progressive forces which seek to redress the balance forces of power which currently results in gross inequalities in health and poorly funded care provision. In this article I wish to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from progress in care giving.

The Politics of care

This summary of a recent article by Curtis (2013) is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:

“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification…..nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness”.

A key point made in the article is that of the requirement for strong nurse leadership in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our sociological imaginations to bear so that we can more fully understand the antecedents to abusive institutional care. These include poorly funded care provision for a low status Cinderella service.

Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’. Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what Graham Scambler (2012) calls the Corporate Class Executive (CCE) and the Political Power Elite (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. One of the critiques of the Mid Staffs tragedy was that corporate self-interest was put ahead of patients’ safety (Francis (2013).

There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them. J K Galbraith coined the phrase ‘private affluence-public squalor’ to describe the mismatch between what is resourced in the private sector and the public:

There’s no question that in my lifetime, the contrast between what I called private affluence and public squalor has become very much greater. What do we worry about? We worry about our schools. We worry about our public recreational facilities. We worry about our law enforcement and our public housing. All of the things that bear upon our standard of living are in the public sector. We don’t worry about the supply of automobiles. We don’t even worry about the supply of foods. Things that come from the private sector are in abundant supply; things that depend on the public sector are widely a problem. We’re a world, as I said in The Affluent Society, of filthy streets and clean houses, poor schools and expensive television. I consider that contrast to be one of my most successful arguments”. (interviewed in 2000).

Galbraith first wrote about this process in 1958.

As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care with an eye to the balance sheet. This results in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios (Salvage 2012). The NHS is no different, but is also now handicapped by various factors making its provision seemingly expensive for society. While the current (2013) Chancellor states that NHS spending will be ringfenced, the true position is that care straddles both health and social care sector provision and is thus characterised by means testing.  It is accepted fact that our population is ageing with forecast increases in dementia and diabetes, health and social care services will experience increased pressures as demands and frailties rise. The argument is about who is going to pay for the provision of care?

Frail elderly people need a lot of care and that care is expensive. Let us not forget our history – why the NHS was set up (Abel Smith 2007), who struggled to get it in into place and why, and the functions women especially played in the private sphere (Elshtain 1981) of care both for children and the elderly. Modern Industrial society was both capitalist and patriarchal with care firmly in the private domain. No state funding as we would recognise it was provided because this was expensive. Patriarchal attitudes would not define it as ‘proper’ work and so could be left to women. The Parish, Poor laws and workhouses were the backstop for those unable to fend for themselves, for those without the family, and that often meant women, looking after them. The working class had to struggle to get health and education properly funded. Enlightened Victorian philanthropists and entrepreneurs realised that if they wanted workers to keep working then recreation and education had to be provided. This provision was despite the capitalist dynamic for profit, not because of it.

We have come a long way as social democratic pressures finally provided the NHS and Education, as the elites also were won over to the need to provide care. The ‘One nation’ Tories at least understood that a prosperous society had to take care of all of its members, of course there was some self interest in this – we needed soldiers who were fit for the battlefield, and we needed healthy workers for the factories. This is a simplistic history as it is more nuanced than this. However, over the last 30 years or so we have seen reversal of this enlightened social democratic outlook on care and public health and care. The need for care is increasing but this is occurring just when the elites are pulling back from their responsibilities. They look at what state provision will cost for high quality elder care and are frightened.  They also have a visceral loathing of state provision…because it costs them money through taxes they do not want to pay. They say it is because the state is inefficient and anti-democratic, that state provision is the road to serfdom. Suffice to say that the current involvement of the CCE with the PPE is extremely antidemocratic but their right wing press cheerleaders have not spotted it or prefer to ignore it.   Seamus Milne  has eloquently exposed how corporate power is corrupting politics.

The neoliberal capitalist agenda (Crouch 2011) requires the state to pull back from earlier involvement on education and health. The CCE and the current PPE have swallowed an ideology that simply accepts private provision = good, public provision = bad. This is why we are seeing the conditions of an affluent society being characterised by a hugely increasing wealth gap. This agenda also allies itself with patriarchal views on the proper role for women – get back in the kitchen girls and look after the kids…and now, of course, Gran as well.

Austerity is now the smokescreen for dismantling of the state provision for care. Does this mean that lack of compassion is directly related to neoliberal policies?  To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that.  Of course poor quality care pre dates capitalism and the NHS, however capitalism (and its often hidden twin patriarchy) sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses will be asked to provide more for less. This has been always the case; nursing work as womens’ work (Hagell 1989) has largely been invisible emotional labour (Smith) which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly.

As Roy Lilley argued on nhs.managers.net:

(The Francis report 2013) talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still.

and…

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line. No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.

Nurse educators and their students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over.  It is not. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse;  hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. ‘Top’ Universities show off their ‘top’ professions: law, medicine, business and science whose courses are oversubscribed due to professional closure and the high salaries they attract. The children of the elite are groomed and public schooled to ensure they attend the ‘right University’ and study the ‘right’ subject while eschewing nursing, which struggles to gain academic credibility and value among society and Russell group elites, while its core concept is seen to require no education at all.

Nurses are in a political struggle whether they realise it or not. For the sake of all us who will require care, don’t let the greedy bastards grind us down

 

 

 

 

 

References:

Abel Smith, B. (1992) The Beveridge Report: its origins and outcomes. International Social Security Review 45 (1-2) pp5-16

Curtis, K. (2013) 21st Century challenges faced by nursing faculty in educating for compassionate practice: Embodied interpretation of phenomenological data.   Nurse Education Today, http://www.nurseeducationtoday.com/article/S0260-6917%2813%2900170-6/abstract

Elshtain, J. (1981) Public Man, Private Woman: Women in Social and Political Thought. Princeton, NJ: Princeton University Press

Scambler, G. (2012) Elements towards a Sociology of the Present. December 6th http://grahamscambler.wordpress.com/2012/12/06/elements-towards-a-sociology-of-the-present/

Undignified Care

The report into poor care at Mid Staffordshire NHS trust is due very soon.

Undignified care.

Why do patients, particularly older patients, experience indignities such as being denied wearing their glasses (“in case you roll over on the pillow and break them”) or being made (forced?) to sit in an armchair (“you know you get dizzy and might fall”). One reason is because of the increasing use of a particular approach to risk management and its procedures that characterise not only society, as exemplified by the ‘high-viz jacket’ phenomenon, but also by healthcare organisations.

This paper on http://plymouth.academia.edu/bennygoodman/Posts

discusses a research report and the implications for care and care management in the NHS and other organisations that links a particular way of thinking, risk management and poor quality care.

What implications do the differences between a social and medical model of health have for the nursing profession?

What implications do the differences between a social and medical model of health have for the nursing profession?

 

(note the hyperlinks in the text)

 

This short paper will address biomedical, social and ecological models of health.

 

Medical model:

First of all we need to be clear what we mean by these terms. A medical model (sometimes called a biomedical model) is based on knowledge about the biological causes of disease. This approach uses the sciences such as physiology, pathophysiology, pharmacology, biology, histopathology and biochemistry. A detailed knowledge of the human anatomy is required as well as detailed knowledge of:

·         Aetiology (in the United States  they spell it Etiology).

·         Epidemiology.

·         Signs and Symptoms.

·         Diagnosis.

·         Investigations and clinical examinations.

·         Treatment options and management plans

for a very wide range of conditions and diseases.

The focus is often on the individual ill patient, and it seeks to cure through the application of medications and/or surgery.

Many doctors in practice however adapt and supplement this basic approach to consider issues such as lifestyle, patient preferences and wishes in their treatment options. This might be termed a biopsychosocial model. Options for treatment also include referral to other professionals such as physiotherapists and dieticians and some doctors refer to complementary therapists.

“While disease dominates biomedical thinking, the biopsychosocial model incorporates social, psychological and emotional factors in diagnosis and treatment. It recognises that illness cannot be studied or treated in isolation from the social and cultural environment. Whereas the biomedical model prioritises professional knowledge, the biopsychosocial model expects health carers and doctors to acknowledge and take into account users’ circumstances.

Medicine practised within a biopsychosocial framework acknowledges the links between socioeconomic deprivation and adverse health. It also considers issues such as improving access to health services and reducing health inequalities as a legitimate and appropriate function of health service provision.”

(source: http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.7)

Thus a biopsychosocial model is a link between the medical approach and the social model of health.

Box 1: This extract is taken from the Open University.

Models of healthcare delivery: the biomedical model:

Biomedicine is also known as allopathy, conventional medicine or modern western scientific medicine).  In the UK biomedicine dominates contemporary and official understandings of health and forms the basis of the NHS and other western health care systems. While the biomedical model is considered the epitome of scientific, objective, reproducible medicine, the actual delivery of health care may be somewhat different in practice. The following statements about biomedicine thus represent an idealised, necessarily artificial version of this model.

·         Health is predominantly viewed as the ‘absence of disease’ and as ‘functional fitness’.

·         Health services are geared mainly towards treating sick and disabled people.

·         A high value is put on the provision of specialist medical services, in mainly institutional settings, typically hospitals or clinics.

·         Doctors and other qualified experts diagnose illness and disease and sanction and supervise the withdrawal of service users from productive labour.

·         The main function of health services is remedial or curative – to get people back to productive labour.

·         Disease and sickness are explained within a biological framework that emphasises the physical nature of disease: that is, it is biologically reductionist.

·         Biomedicine works from a pathogenic (origins of disease) focus, emphasising risk factors and establishing abnormality (and normality).

·         A high value is put on using scientific methods of research and on scientific knowledge.

·         Qualitative evidence (given by lay people or produced through academic research) generally has a lower status as knowledge than quantitative evidence.

(Source: adapted from Jones, 1994 in http://openlearn.open.ac.uk/mod/oucontent/view.php?id=398060&section=1.6)

 

The Social Model

The social model of health focuses on the social distribution of health and illness between different groups (e.g. death rates which vary between social classes).  The social model is interested in the social causes of ill health best illustrated by the Social Determinants of Health (World Health Organisation 2008) approach.

The Social determinants of health

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission’s final report was launched in August 2008, and contained three overarching recommendations:

1. Improve daily living conditions

2. Tackle the inequitable distribution of power, money, and resources

3. Measure and understand the problem and assess the impact of action

The WHO Conference Secretariat has now put together the full Report of the World Conference (66 pages with color pictures). A 16 page summary Report is also available. World Health Assembly adopts the Rio Political Declaration on Social Determinants of Health. A resolution endorsing the Rio Political Declaration on Social Determinants of Health was adopted in May 2012 by WHO Member States at the Sixty-fifth World Health Assembly (WHA) in Geneva, Switzerland.

http://www.who.int/social_determinants/en/

 

 

Barton and Grant (2006) have developed  a ‘health map’ which illustrates the global, environmental as well as the social antecedents for health:

 

http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post

Barton, H. and Grant, M. (2006) A health map for the local human habitat. The Journal for the Royal Society for the Promotion of Health, 126 (6). pp. 252-253.

 

Note that the outer ring includes the ecosystem so this firmly locates human health within the ecology of the planet. Therefore health stems from the biogeophysical environment in which humans live and are an inescapable part of. This perspective which sees no separation of humanity from ecology suggests that no one can be healthy in an unhealthy environment. This might take the position that if the oceans are increasingly acidic, resulting in fish species loss, then by definition human populations are not healthy either.

Health is then social and ecologically determined, experienced within the social relationships in a material world. No one lives alone and so it is in the coming together in communities and societies that we fashion the determinants of health. There is a biological basis for some individuals, however genetic determinants (e.g. in cystic fibrosis) operate at this individual level and are manifest in a relatively minor way. This is not to deny that for the individual the medical condition is anything but minor, but health on population levels are not determined thus. Even genetic manifestations are at times made worse or better by the social conditions in which the individual finds themselves. Poverty has a knack of making underlying biological problems much worse. Climate change may also make both poverty and the health status of populations worse.??

Social Conditions??

If health is socially determined by social relationships, what are the current forms of social relationships that give rise to certain patterns of health, illness and disease? We know from studying inequalities in health that socio-economic conditions and relative social status determine populations’ health status including measurable outcomes such as life expectancy and the under 5 mortality rate. Other social relationships such as gender and ethnicity also affect health status. I would argue that major influences upon global health are the socio-economic relationships which are based on a certain forms of political economy, i.e. capitalism.

Implications for Nursing:

The following is a gross simplification, a continuum if you like, of the two typologies. In practice a nurses will develop their own mix of the two approaches:

Biomedicine focuses on the ill individual, social models focus in healthy populations. A biomedical nurse would use mainly the medical sciences to help cure the individual , A social model nurse would draw from various disciplines (sociology, psychology) to promote health and well-being of populations. A biomedical nurse would be drawn to acute care, especially critical care while a social model nurse may be drawn to primary care and public health. A biomedical model seeks to change the individual,  A social model nurse would seek to change society. A biomedical nurse has little need for history and politics, a social model nurse understands her history and political action.  A biomedical nurse has little need to use a sociological imagination, a social model nurse needs to develop her sociological imagination.

A biomedical nurse may ignore ‘non-scientific’ approaches to cure, a social model nurse might value alternative and complementary approaches. A biomedical nurse wants to cure, a social model nurse wants to care. Biomedical nurses implicitly positively acknowledge higher stuts of medicine, a social model nurse gives no privileged status to medical practice. biomedical nursing mirrors male ways of thinking, social models open themselves up to female and post-colonial ways of thinking.

 

 

 

 

A note on ‘econursing’ or an ecological model of health.

Taking on board Barton and Grant’s health map, acknowledging for example the health impacts of climate change,  and the building upon a social determinants approach, an ecomodel would emphasise that human experience cannot be understood as separate from nature. Philosophically it critiques the dualist assumptions that see nature separate from humanity, what has been called ‘human exceptualism’. This is the position that sees us as exceptions from nature, we are separate from it, and nature is open for domination and control for the benefit of humankind. From an eco-perspective, this is extremely damaging to human health and to the health of the planet, more than that, they are the same thing.

Benny Goodman 2012

How might social factors influence experiences of health & illness?

…and ‘How might this be relevant to the work of the nurse’?

 

 

What do we mean by social factors? This term covers a multiple meanings, but lets start by thinking about what people and society do and the categories we place ourselves, and others, into. A social factor then is something that might have an effect on us as we go about our daily lives as social actors. Emile Durkheim in ‘The Rules of Sociological Method’ (1895) wrote about ‘social facts’ as almost having a life of their own:  “treat social facts as things” existing outside of our individual consciousness. The common categories or factors include things like:

 

 

Socio economic status.

Ethnicity.

Gender.

 

We might also want to consider social structures such as:

 

Family.

Leisure, Work and Occupations.

Education.

Politics.

Military–Industrial Complex.

Religion.

Consumer-Industrial Complex.

 

Before we proceed just consider how the above social structures have changed over time.

 

The following will discuss obesity and a heart attack using our sociological imagination. I will then consider the relevance for nursing.

Obesity

 

To illustrate how any of these affect health we could take the issue of Obesity. Why are populations globally all getting fatter over the past couple of decades? A biological explanation founders in that it requires some biological mechanism that has changed for billions of people. Evolution does not work that fast. As there are differences between groups of people and individuals there is something psychological and or sociological happening.

 

It might be linked to one’s socio-economic status, as we know that poverty and economic and social deprivation are correlated to increased weight in populations. McLaren (2007) argues that obesity is a social phenomenon. That is to say it is just not a physical or biological condition to be explained or dealt with only in physical terms (e.g. the injunction to eat less and exercise more). Action on obesity includes targeting both economic and sociocultural factors. McLaren illustrates the varying social patterns involved in level of obesity in this review of studies.

 

Roberts and Edwards (2010) suggest that world-wide, over a billion adults are overweight and 300 million are officially obese. Their book ‘The Energy Glut’ suggests that how energy is both sourced, e.g. oil, and used, e.g. car driving, is directly linked to growing obesity. They suggest ‘fatness’ and climate change, are manifestations of the same fundamental cause. It is down to how oil based fossil fuel energy, after being discovered, started not only the process of catastrophic climate change, but also propelled the average human weight distribution upwards.

 

In addition they suggest that the food industry uses sophisticated marketing techniques to sell us mountains of energy-dense food whilst at the same time we are ‘functionally paralysed’. We just don’t move about as we used to, partly because the opportunities to do so diminish. This could be seen especially in the UK with increased car use, road building, living miles from work and the growth of retail outlets built out of town to exploit car use, poor public transport and poor cycling infrastructure. The accumulation of body fat is therefore a political, not a personal, problem.

 

 

 

 

 

 

 

The Information Centre has published Statistics on Obesity, Physical Activity and Diet: England 2012. The topics covered in the report include, overweight and obesity prevalence among adults and children, physical activity levels among adults and children, trends in purchases and consumption of food and drink and energy intake and health outcomes of being overweight or obese.

 

http://www.ic.nhs.uk/pubs/opad12

 

Key facts

         In 2010, just over a quarter of adults (26 per cent of both men and women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over). For the same period, around three in ten boys and girls (aged 2 to 15) were classed as either overweight or obese (31 per cent and 29 per cent respectively).

         In 2010, 41 per cent of respondents (aged 2+) said they made walks of 20 minutes or more at least 3 times a week and an additional 23 per cent said they did so at least once or twice a week in Great Britain (GB). However, 20 per cent of respondents reported that they took walks of at least 20 minutes “less than once a year or never” in GB.

         In 2010, 25 per cent of men and 27 per cent of women consumed the recommended five or more portions of fruit and vegetables daily.

         The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages was 11,574 in 2010/11. This is over ten times as high as the number in 2000/01 (1,054).

 

 

In 2010, there were 1.1 million prescription items for the treatment of obesity, a 24 per cent decrease on the previous year when 1.4 million items were dispensed. This is the first recorded decrease in seven years.

 

 

 

Heart Attacks

 

Wright Mills (1959) wrote:

 

 ‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).

 

A middle aged man has a heart attack but he does not consider that his illness may be linked to living in the 21st century, or that the roots of his illness may lie in current society.

 

He is:

 

 ‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).

 

Lying in a hospital bed, with ECG electrodes stuck to his chest, the man may curse his luck or put his condition to being overweight, his smoking habit and lack of exercise.

 

He does not:

 

‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’  (p4). 

 

In addition he:

 

‘..cannot cope with their personal troubles (his heart attack) in such ways as to control the structural transformations that lie behind them.’  (p4).

 

(my italics).

 

What ‘structural transformations’ (social factors) might lie behind the heart attack, or an eating disorder or binge drinking? What is a ‘structural transformation?’

 

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society ‘works’ when individuals, groups, communities and populations decide to act out their relationships one with another and in doing so create (and are created by) social ‘structures’.  I have listed some structures on page 1.

 

In the above heart attack case what structures are there and what are those structures that lie beneath his personal trouble?

 

To help answer that question Wright Mills argued that:

 

‘what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves…this quality…(is) the sociological imagination.’ (p5).

 

So we need to use information and reason to start making the links between society and illness. A heart attack results from a variety of sources. Some may be genetic, but others are patterns of living which are subject to social structure. The middle aged man just happened to have been born in the 1950’s into a working class background in Liverpool. His father worked as a docker and he in turn followed in his father’s footsteps.

 

Social class is a form of social structure. Living in working class Liverpool during the 1950’s to the 1970’s means engaging in certain eating habits, wearing certain clothes, taking holidays in certain places (in the UK) and following certain football teams. And, of course, smoking. Smoking is as natural an activity as breathing, even Division One footballers smoke. The ‘metrosexual’ man does not exist yet, there are no ‘Men’s Health’ magazines, cigarettes are cheap, there are no laws banning smoking in public places. The idea of working out in a gym does not feature except in the working class boxing clubs. Olive oil and the Mediterranean diet exist only in the Mediterranean. Eating (saturated fat) red meat is masculine. ‘Jogging’ has not entered into the English language yet, exercise is for athletes or only takes place when playing Sunday football for the local pub team. Car use is becoming more common and cycling is in decline. Margaret Thatcher was soon to say that a 30 year old man on a bus is a failure so public transport is only for those who have to.

 

The social structure of this man’s early years involve lifestyles that increase his chance of a heart attack but he was not aware of all the connections. He thinks all his choices are his own, but he is unaware that choice is limited and results from those chances handed out to him. His choices are also based on imperfect information and also upon the wishes of others who want him to make certain choices (e.g. the cigarette manufacturers). If the society in which he lives offers him the choice of A, B and C and he chooses A, he may think he has made a real choice. But what if there is choice F, G and H that he is not aware of through circumstance or that history has not yet provided?

 

in 1950, one could choose to smoke anywhere and the lack of a strong public health campaign and research evidence did not point to the deadly nature of the practice. The personal trouble of smoking has to be seen in the context of that history.

 

Fast forward to 2010 and a new historical period. The public issue of millions dying of lung cancer has affected change in society and now impacts differently upon the individual. Social structures have been transformed since the 1950’s. For example, we now think of smoking not as glamorous but as a ‘filthy habit’. Men no longer congregate in pubs where everyone smokes inside.

 

‘The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).

 

Thus, the middle aged heart attack victim who has this ‘quality of mind’ would understand his present trouble as linked to the context of 1950’s Britain where working class life took smoking for granted. He knows that all his friends smoke and that the likelihood of him smoking is high, given the social context and the time in which he lives.

 

 

Nursing relevance

 

This depends on where the nurse works. In an intensive care unit or in many acute settings, it is irrelevant to the everyday clinical practice of giving physical care. In primary care however, understanding how social factors impact on people’s lives may suggest strategies for mitigating them and for engaging in health promotion and health education. The obvious is knowledge for healthy eating habits or exploring personal physical activity levels.

 

However, certain issues will require action at the community or political level. This calls into question the social and political role both for the individual nurses and for nursing as a profession. Public health is a core part of nurse education and thus understanding social causes for ill health is part of the public health role for nursing. Wright Mills argues that it is the job of the social scientist or the liberal educator to foster the sociological imagination so that people become aware of how social factors (in our case) affect health and illness. We could argue that this applies to nurses in that once we know what causes disease we might have a duty to do something about it at the social level if it is caused by social factors (i.e. the ‘Social Determinants of Health’).

 

At the very least we should be very wary of victim blaming or accepting wholesale simplistic arguments over personal responsibility, see for example Wind Cowle (2012), while at the same time we do very little to curb fast food outlets, regulate the food industry, curb car use through urban planning or encouraging active travel alternatives such as cycling. 

 

Nursing has various elements to it: giving direct patient care, working in a team, managing oneself and personal development. To that we could add the need for networking and political awareness to exercise nursing leadership. Therefore I suggest that developing an understanding of the social factors involved in health and illness can assist a nurse in developing in these various elements to various degrees regardless of where one works.

 

 

Benny Goodman 2012

 

 

 

 

References.

 

McLaren, S. (2007) Socioeconomic status and obesity. Epidemiological Reviews 29 (1): 29-48.http://epirev.oxfordjournals.org/content/29/1/29.abstract

 

Roberts, I. and Edwards P (2010) The Energy glut. The Politics of fatness in an overheating world. Zed Books

 

Wind Cowle, M (2012) The NHS needs people to be more responsible http://www.guardian.co.uk/society/2012/sep/25/nhs-needs-people-be-more-responsible

 

World Health Organisation (2008) Closing the Gap in a generation. The Social Determinants of Health. http://www.who.int/social_determinants/en/

 

Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.

 

 

 

 

 

 

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