Nursing and Health in Society

University Degree Subjects allied to Medicine

Module 2 assignment

The intention of this essay is to explore an inequality in health, which has been observed in practice. It will be argued that poverty does affect many people in our society and the lack of resources of poorer people in society, are at the root of inequalities in health. By means of reflecting on personal experiences, the wider psychosocial influences will be considered and how social policy and legislation address this inequality and reflect on the implications for nursing practice.

There are a number of definitions of what Inequality of health mean, and two general explanations are:

“Ideally everyone should have the same opportunity to attain the highest level of health and more pragmatically, none should be unduly disadvantaged”

(Whitehead 1987 p6)

A definition of Inequality from the online Cambridge advanced learner’s dictionary stats:

“A lack of equality or fair treatment in the sharing of wealth or opportunities between different groups in society.”

(Cambridge University Press 2006)

There have been several pieces of well-documented research into health inequalities, by successive governments and independent bodies, for example, The Black Report in 1990; Margaret Whitehead’s ‘The health divide’ in 1987 (Stephens et al, 1998) and more recently the Acheson Report in 1998. This research underlines the correlation between poverty and ill health and the disparity that exists, depending on social class. Measurements and comparisons are made in terms of morbidity and in terms of mortality. Research shows that if a person is born into poverty his/her chances of suffering ill health and a shortened life span are greater than if he/she was born into prosperity. Some of the most recent research has shown, for example that children in social class five (where five represents the least well off and one represents the most well off) are five times as likely to suffer accidental death than their peers from social class one (Roberts I & Power C 1996). Further studies show that how long one lives, is powerfully shaped by one’s place in the hierarchies built around occupation, education and income (Graham 2004).

Explanations for poverty tend to fall into two categories, absolute and relative. The first of the two identified forms of poverty is ‘absolute’ or subsistence level poverty (Thompson and Priestly 1996 p207). Income falls below a set level so that a person does not have the means to be able to secure the basic necessities for living, in terms of food, drink, shelter and clothing. Stephens et al (1998) argue that for some people in society, like rough sleepers, poverty in absolute terms is very real and that when older people die from hypothermia because they cannot afford to heat their homes adequately, it is as a result of absolute poverty. Poverty in this sense however, has certainly diminished since the advent of the welfare state.

The second definition of poverty, ‘relative’ poverty, is defined in terms of a reasonable standard of living, generally expected by the society in which a person lives. It identifies ‘needs’ as more than basic biological requirements, taking into account social and emotional needs. It is also about being excluded from taking part in activities, which are widely undertaken by the rest of society. In terms of resources, relative poverty is a higher standard of living than absolute poverty, but it could be argued that many things that are not strictly essential for life nevertheless could be deemed as necessities by society in general. It is clear that there are certain people in society who suffer from poverty, Stevens et al (1998) maintains that it is important to capitalise on the advantages of both definitions.

Poverty and its causes have been debated (Bradshaw 2000), Seebohm Rowntree looked at different classes in society and tried to establish the extent of poverty and how that influenced people’s health in the community. From his findings he established a poverty line and classed people as either living in absolute or relative poverty. Relying on the research of Rowntree, Sir William Beveridge also looked at poverty and published the Beveridge report on National Insurance and allied services. The aim of this report was to establish a welfare state and abolish the Five Giants, which consisted of:

Want
Squalor
Idleness
Disease
Ignorance

The social security systems were then put in place and aimed to be the National Insurance Act (1946), this meant that all employees would pay a flat rate of their income. He also implemented the establishment of the 1945 Family Allowances Act. This was incorporated to give a better standard of living.

The Black Report (1980) on ‘Inequalities in Health’, followed, which involved Sir Douglas Black, who was appointed to address and update inequalities in health. He took a different approach in his explanation. The report stressed the emphasis of material conditions of life and factors outside the NHS (Ham 2004). Factors such as income, housing and the nature of employment have all fractured working class experiences and need to be considered (Black 1982). The Black report however, was not taken seriously until almost twenty years later, when the results of the Acheson inquiry was made available in 1998, they not only confirmed the analysis of the Black Report, they also found that in some respects, inequalities had widened (Ham 2004). The report brought awareness of areas where future policies need to be put in place to reduce health inequalities, education was one of the areas, as it has a high influence when promoting health, studies show that low levels of education achievement correlates with poor health (Acheson 1998).

Over recent years reflection has become an important aspect of nurse training, according to Taylor (2000) the general view is to reflect on personal experiences which can provide the student nurse with the opportunity to form their own views of a situation, therefore the ability to analyse the quality of their actions. In order to help me with my reflection, I have chosen Gibbs (1988) model. This model has six points, description, feelings, evaluation, analysis, and conclusion and action plan. Using these points as headings I am able to reflect fully on the case involved.

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Description

The case that will be discussed, is one in which I observed whilst out on my Mental Health placement, on a psychiatric unit. The age range on this low secure unit is eighteen – sixty years, with many different Mental Health issues. This particular case involves a twenty five year old man, admitted to the unit for Alcohol Detoxification. In order to respect the rights of confidentially and comply with the NMC, throughout this report, the young man will be referred to as Ben. (NMC 2004)

Following Ben’s admission, using the Tidal Modal, (A series of questions from childhood to present time) the main objective of this interview, is to gather information in order to assess which services will best benefit Ben to aid him with abstinence from alcohol. At the beginning of the interview it was explained to Ben that anything he told me would be confidential unless he disclosed anything that I felt was harmful to himself or to anyone else (NMC 2004). It was then explained that in order to assess his situation, details of his background would be needed.

Ben was started on the Clinical Institute Withdrawal Assessment (CIWA) for alcohol Detoxification (appendix 1). The CIWA scoring chart goes through a series of observations and questions every ninety minutes, to assess whether the patient is in need of medication to help with the withdrawal.

Ben was born in 1981 and has been brought up with his mother and two brothers, one older and one younger. His father left the family home when Ben was a young boy and has had no contact since. Ben and his family lived in a council house in a deprived area of the city, where his mother worked two part time jobs and at the same time brought up the three children, with Ben being the middle child. Ben reflected the lack of money in the household for basic necessities such as heating, food and clothing. He said that his mother seemed to be always tired and worried about household bills, therefore she wanted the children to leave her alone as much as possible. This meant that Ben often played truant from school and hung around with friends late at night, in winter Ben said it was often warmer outside than in his shared bedroom with no heating. Ben believes that his lack of any educational qualifications has held him back since leaving school and stopped him from getting a well-paid job. He said as he grew through adolescence there were lots of tensions in the house between himself and his other brothers and it was the feelings of despair that led him to experiment with drugs as a teenager. He said the drugs became a coping mechanism and therefore become a normal part of his life. Following a benefits investigation involving Ben’s mother, he was asked by her to leave the family home, as the Council had threatened to cut her housing benefit because Ben’s jobs seekers allowance would be included as additional family income in any housing benefit claim.

After spending many nights at different friends houses, Ben found himself without a job and living on the streets. At the age of twenty, Ben became involved with a group who abused hard drugs, and his drug intake eventually progressed from smoking cannabis to injecting heroin. After many months of living on the streets and abusing his body with drugs, Ben became sick and was taken into hospital where he was diagnosed with hepatitis C. Ben stayed in hospital for a few weeks and was then helped by an organisation called Kaleidoscope. Kaleidoscope is successful in attracting drug dependants to its services and has features which research has shown are effective at reducing injecting heroin use and criminality. (Kaleidoscope project online)

With the help of kaleidoscope, Ben was placed in a hostel and eventually decided to disconnect himself from his drug acquaintances and is currently undergoing a Methadone program. Ben began to get his life back on track and managed to gain some employment. Ben met back up with a previous girlfriend whom had left him when he became mixed up with drugs and after a few months of dating, Ben’s girlfriend became pregnant. At this time she was living with her parents twenty miles away and the prospect of having a baby who might have contracted Hepatitis C, she decided to have an abortion and terminate her relationship with Ben.

Ben became withdrawn and depressed, not bothering to turn up for work, he immediately started to abuse alcohol. Still carrying on with the methadone, Ben was drinking in excess of three bottles of sherry per day. Kaleidoscope referred Ben to the Gwent Alcohol Project (GAP) who referred Ben to the Psychiatric unit for Alcohol detoxification, now at age twenty-five. Ben was admitted to the ward for four days and within thirty minutes of arriving, he was assessed using the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA).

Feelings

Ben arrived on the ward early on a Tuesday morning, brought in by Gwent Alcohol Project (GAP), which is an initiative of the Gwent Alcohol and Drug Misuse charity and is currently jointly funded by the Gwent Health Authority, the Welsh Assembly and the four Unitary Authorities of Newport, Blaenau Gwent, Monmouthshire and Torfaen. The project also enjoys the benefits of a partnership agreement with Gwent Probation Services. (GAP Online) I was asked to show Ben around the ward and where he would be sleeping. He seemed very nervous and anxious, but extremely polite when speaking to staff on the ward.

As this was my third week on the ward, I had settled in very well and was really enjoying my placement. My mentor asked me if I felt confident enough to undertake Ben’s admission on my own, I jumped at the chance and felt humbled at the trust and responsibility my mentor had just given me. I gathered all the necessary paperwork that I would need and explained to Ben that there are a series of questions that would delve back into his childhood. It soon became apparent to me that Ben was using alcohol as a result of negative cognitions associated with low self-esteem and depression, he expressed to me that alcohol helped to alleviate his feelings of depression.

Afterwards I talked about it with my mentor, she said that Ben was here for the treatment of alcohol detoxification and not depression, he would have to be re-admitted on another occasion to deal with his depression.

Evaluation

The Bad Points

The Department of Health guide entitled ‘Building Bridges – A guide to arrangements for the care and protection of severely mentally ill patients (1995) recognises the existence of a dual diagnosis. The guide says:

Drug and/or alcohol misuse can have a significant impact on the well-being and risk status of mentally ill people. People with a dual diagnosis of mental illness may require treatment from both sets of specialist services and close links need to be maintained at provider level to insure that such care is properly co-ordinated (p.42).

Ben was being treated for alcohol detoxification and not depression, although it could be said that Ben’s depression was the cause of his alcohol problem. However, there is no national strategy on dual diagnosis either at a political or professional level, where mental health problems co-exist with an addiction problem, intervention strategies appear to be based on the assumption that until the mental health problem has been addressed there was little or nothing that could be done by a substance misuse service to help the patient. If people were referred to a service with a dual diagnosis and they were assessed by these services as either substance misuse, with minor mental health problems, or people with major mental health problems who also happened to have a substance misuse problem. Their dual diagnosis would not be seen as a specific problem and therefore deserving of a planned and comprehensive response Checinski (1996), cited in Rorstad (1996). It is therefore noted that Ben previously has failed to access adequate treatment for his depression.

The good points

As Ben is already in close contact with Kaleidoscope and GAP, he will be supported in the community when he leaves hospital. Both organisations provide free and confidential counselling on a one-to-one basis, enabling clients to explore their concerns, determine their own goals, which may include abstinence or controlled drinking and work towards improving the quality of their lives. The counselling Ben will receive, will sense out influences that were already operating when Ben began to take drugs and alcohol, in order to go forward to understand the subsequent impact on his environment, life events, personal relations, mental state and other relevant factors. Also, it will be useful to gain an understanding of the pressures and circumstances, which have caused, contributed, or shaped his drinking pattern.

Although it may be argued logically that the appropriate treatment goal for patients with dual diagnosis is to address both the substance misuse and the psychiatric symptoms, this fact has in the past been overlooked in Ben’s case. It is important that Ben’s treatment requires dual goals, namely, abstinence from alcohol and stabilisation of his depressive symptoms. It will therefore be important for kaleidoscope and GAP counsellors to liase with each other on a regular basis, so that they are both aware of treatment outcomes and any underlying problems that could prove useful in the process of helping Ben to start living a ‘normal’ life.

Analysis

Looking back at Ben’s childhood, it appears that much of it was spent in poverty with a lack of basic necessities for daily living. His mother worked hard and tried to make ends meet, but this often left her exhausted, frustrated and worried about financial matters. Ben’s childcare needs were often overridden by his mother’s desire to pay the bills or have essential services such as gas and electric reconnected after disconnection. This left Ben and his brothers free to truant school and hang around other people with low esteem and no real goals in life other than day-to-day survival. When Ben’s mother asked him to leave, Ben felt that he had no choice but to leave his family home as his mother’s housing benefit was under threat of being cut.

Cultural and behavioural explanations for inequalities in health emphasise the importance of differences in social circumstances and in ways in which individuals in different social groups choose to lead their lives, in other words, in the behaviour and voluntary lifestyles they adopt. Thus inequalities in health evolve because lower social groups have adopted more dangerous and health damaging behaviour than the higher social groups, and may have less interest in protecting their health for the future (Whitehead 1988). Finally, exhausting his welcome at friends’ houses, Ben found that he was living in absolute poverty on the streets in his local city. The National Homelessness Strategy for Wales (2006 – 2008) points out that many new initiatives for rough sleepers have been developed, including outreach and day services, mainly with funding from the Assembly Government.

The Welsh Assembly Government has a long established objective to end the need for anyone to sleep rough, by ensuring that all rough sleepers have some form of accommodation to go to if they wish. However, for Ben this was clearly not the case, as he found that with no fixed address there was no one that he new of could help him. In many areas there is no direct access provision, and much of that accommodation is full and in practice not available to rough sleepers when they need it. The National Homelessness Strategy for Wales (2006 – 2008)

Ben’s involvement with drugs had an impact on his health, after years of sleeping on the streets and injecting himself with heroin, Ben contracted hepatitis C and became very ill. The Homelessness Strategy, recognise that in the most extreme cases there are rough sleepers, living a way of life which can cause irreparable harm to their health and well-being. They go on to say that they are committed to eliminating the need for rough sleeping in Wales. After Ben’s treatment in hospital for hepatitis C, he was helped by Kaleidoscope, who found him hostel accommodation and introduced him onto the Methadone program. Methadone is a rigorously well-tested medication that is safe and efficacious for the treatment of narcotic withdrawal and dependence. Heroin releases an excess of dopamine in the body and causes users to need an opiate continuously occupying the opioid receptor in the brain. Methadone occupies this receptor and is the stabilising factor that permits addicts on methadone to change their behaviour and to discontinue heroin use (ONDCP Fact sheet).

Ben appeared to be getting his life back together and also managed to gain some employment, he also got back together with an old girlfriend. Things seemed to be going smoothly for Ben until his girlfriend became pregnant and consequently found out that Ben had been diagnosed with hepatitis C. She was furious with Ben as he had not told her about it and she decided to terminate the pregnancy and her relationship with Ben. Following this Ben became very depressed and not wanting to turn to drugs, he started to heavily consume alcohol. Wright (2006) points out that there is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain. When kaleidoscope referred Ben to GAP, he had been consuming large amounts of alcohol over a few years and consequently had also lost his job. GAP referred Ben to the psychiatric unit for detoxification from alcohol. Teams admitting people to hospital are to consider practicalities such as keeping up rent or utilities payments as part of the care plan. They are to work with housing and advice agencies to ensure that people will not be homeless following discharge, and that their housing conditions do not undermine their recovery (National Service Framework 2005). When Ben was admitted to the ward and started on the CIWA scoring, it took Ben a long time to score enough to be given medication, Ben’s doctor had said that this could be due to the fact that Ben was also receiving methadone.

The mental health NSF 2005 action plan for Wales, state that improving the mental health and well-being of the people of Wales and delivering improved mental health services, continues to be a key health and social care priority for the Welsh Assembly Government. Services are rightly adopting a holistic approach that looks at the need of individuals rather than simply trying to treat symptoms and labelling people with a diagnosis. However it seems that Ben was just being treated for alcohol rather than looking at the whole picture in a holistic way, where Ben should have been treated for depression at the same time.

Government policy is geared to combating inequalities, in light of the findings of the Acheson Report. In particular it recognises the needs of those who may have multiple disadvantages. Social care workers should have an awareness of combined inequalities and should have a commitment to reduce them. Jones (1997) states that, many social workers invest considerable efforts to maximise the welfare benefits of their clients and search through charitable resources to alleviate some of their acute hardships (p.121).

Conclusion

By using the Gibbs (1998) model, each component is associated with a key question. The principle of this model is based on the idea that the reflective process is described as a ‘cycle’ because of repeated clockwise movements; it gives a deeper awareness, increases knowledge and skilfulness. It has looked at a young man who has become a victim of inequalities. And we have seen that a major obstacle to reducing health inequalities is that successive governments have been preoccupied with health services rather than health. Whilst there is a relationship between poor care provision and ill health, it is far weaker than that between low economic status and ill health.

It has been suggested that depression-like symptoms in patients with alcohol problems are transient, alcohol induced effects that neither predate alcohol nor persist beyond it. However, it is possible that depression could increase the likelihood of subsequent alcohol problems.

Stephens (1998) suggests that the best way to get rid of poverty, absolute or relative, is to forge a more genuinely equal society. Social care workers can help to reduce the negative effects of poverty to a certain extent but, for any major improvements to be made, there needs to be a radical change through governmental policy in the distribution of both power and wealth.

We have found that people in Wales do in-fact live their lives in absolute poverty; however there is help for those people that choose to use it. Although the government has put policies in place, such as the National Service Framework, there are still inequalities that exist in health. The NSF for Mental Health has some logical and achievable goals in which nurses carry out during their daily procedures. However we also found that although Ben was in hospital being treated for alcohol detoxification, he should have also been treated for depression at the same time.

The concept of a society where everyone has the same opportunities and all are equal is a fallacy when viewed from a structural perspective. This does not however, mean that people are absolutely powerless to help themselves and assumptions should not be made that because someone is in poverty they will necessarily need the help of social care professionals.

Action Plan

Looking back on my experience with Ben in a psychiatric setting, I feel that there is need for implementation for treatment of dual diagnosis and if the same situation arose again, a better understanding of mental health issues and the policies and NSF’s in place would put me in a better situation to argue the case for the patient.

Conclusion

Over the last decade, the gap in good health between rich and poor has become wider and inequalities in health are large and increasing. Although huge advances have been made in the medical and surgical treatments of illness over many years, our society is still divided in terms of good health.

The structure of National health services is based around the National Health Service (NHS), which was formed in 1948 by the National Health Service Act. The Act brought the health services in particular the hospitals, under the control of the Department of Health in Westminster, but since devolution in 1999 responsibility for health in Wales has been devolved to the National Assembly for Wales. A former Minister for Health and Social Services in the Welsh Assembly Government stated that:

“Strong partnerships between the NHS, local government, communities and the voluntary sector are at the heart of our new and inclusive approach to health.”

Jane Hutt (p.11)

The previous reports that have been identified from Rowntree, Beveridge, and Acheson, have all sought to highlight inequalities in health through the years. Reports that have shown inequalities in health, it can be argued, have resulted in governments improving policies, which attempted to address the issues associated with an inequality in health.

References

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Gwent Alcohol Project (2006) Concerned About Drinking:

Accessed: 21/4/06

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