Book review – “Challenging the Politics of Early Intervention: Who’s ‘Saving’ Children and Why”, by Val Gillies, Rosalind Edwards and Nicola Horsley.

I received a copy of this book from the publisher (Policy Press) in return for a fair and considered review. I approach this book from the perspective of a current practitioner (in health services), but with an academic/research background.

This is an excellent review of the underlying politics and interests underlying the prevailing social investment model of early intervention for children in the UK, and it is particularly excellent and thorough in dismantling the ‘Emperor’s New Clothes’ fetishisation of poorly interpreted neuroscience which forms the basis of much policy and current practice in early intervention. The historical roots of this approach provided fascinating background to what has become a largely cross-party consensus (though for differing reasons, depending on one’s political hue) that individual work with children and their primary caregiver (primarily the mother) is prioritised over the improvement of the social and material conditions in which children and their families live. The outlining of the various interest groups involved (political, business, philanthrocapitalist, and certain practitioner groups), as well as their problematic co-opting of poorly- (or over-) interpreted brain science, laid bare the underlying (not always entirely philanthropic) motivations for the development of this consensus, and paved the way for a blistering – and very timely – exposure of the overal social investment consensus as effacing gender, race and class factors impacting on children’s development. Further insights from practitioners highlighted indeed how, as the authors state on p.119, “Practitioners work in contexts where there is little internal questioning about the general endeavour of early intervention”, but instead accept the over-simplistic and poorly interpreted brain studies as a foundational evidence base and theoretical justification for their practice – a situation which arguably also applies to the policy makers and managers charged with developing and implementing these practices.

Whilst the book is specific to the UK context, in fact it is primarily England-focused, with just a couple of mentions of other policy initiatives (primarily the Named Person, currently contested and undergoing revision in the light of significant opposition and legal challenge) in Scotland. I would have liked to have seen a little more from parts of the UK other than England, whilst recognising that the underlying points and background apply to early intervention policy across the UK nations. Another concern echoes a previous Amazon reviewer*, which is that whilst this is an excellently argued and thorough academic critique of the current situation in policy, and in fact it does indeed end with a call for a collective rather than individualised response to social harm, moving away from an all-encompassing prioritisation of “risk” (a call with which I entirely agree), nevertheless as a practitioner I found I was looking for some practical suggestions of what to do in cases where individual responses and involvement with individual families is entirely justified, and required quickly. There may well be scope for further work in this area, if the authors are able to link with practitioners, academics, policy makers and service managers who share their concerns and misgivings. I would also have liked to have seen more input from professional bodies, as the bulk of those participating in the case study and interview part of the book were from the voluntary or non-statutory sector (it was unclear whether the FNP nurses interviewed were working within or outwith the NHS, although earlier the book had identified the decoupling of the FNP service from other statutory services in England). Perspectives from groups such as the Institute of Health Visiting, or other social work bodies, for example, would have been interesting and may have added a further layer of nuance to the authors’ arguments.

Overall though this has provided me with an immense amount upon which to reflect as a practitioner, and I recommend it wholeheartedly. It would be ideal not only for students of social policy and health/social work management, but also would offer valuable insights to practitioner training courses (social work, teaching, health visiting, etc).

Thank you very much to Policy Press for this opportunity!

* Simon Haworth on 29 September 2017 included in his amazon review the following, with which I absolutely agree: “One potential criticism is that, perceptive and value-based as the book is, it does at times seem to move too far way from the dilemma-laden nature of frontline practice, where difficult and emotive decisions do need to be made to protect children, even when it is evident that the system has failed the family.”

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New transcription and proofreading business

This month I have an exciting new venture to report. I have been looking for a while at how to be further involved in supporting research outwith academia. I am involved in some academic writing (more on that when it is published!), but the prospect of being a freelancer has appealed for a long time, as I seek both flexibility and portability in order to work around my family and other commitments. I have therefore set myself up as a freelance transcriber and proofreader and am now open for business! Please see the “Transcription and Proofreading Services” page on this blog for details of how to get in touch.

For transcription, I am primarily focusing on qualitative interviews and focus groups, but I am also happy to work with files from other scenarios such as seminars, meetings, or conference presentations amongst others. Whilst I expect the majority of my business to come from academia, if you are working elsewhere in the public or voluntary sectors and have sound files which need transcribing, then please do get in touch and we can discuss your requirements and my rates.

For proofreading, I am initially focusing on academic manuscripts, including providing a service for authors where English is not their first language. I am currently undertaking a proofreading and copy-editing course from Chapterhouse and hope that in the future this can also lead me to some freelance work within the publishing sector.

As someone who has previously marked student work as a tutor, I have for some time been concerned about the rise of companies ostensibly providing a “proofreading” service but in effect writing the work for the student. I will not be involved in this type of work, as I consider it highly unethical. In order to protect both myself and the student from this type of exploitative work, if you are a student wishing your work to be proofread then I would ask that you arrange for your supervisor to contact me first to discuss the requirements of the job.

Initially, due to the part-time nature of this venture (which I am undertaking alongside my regular health visiting post), I am primarily available to work on Tuesdays, with occasional other afternoons. My intention is that as I gain more work I will be able to extend the time I spend on this business, and hopefully on your work!

Please do get in touch if you are looking for transcription or proofreading services, and I will be happy to discuss your requirements further. I look forward to a fruitful working relationship!

REPOSE trial – final report

Earlier this year the final report came out for the REPOSE trial. This was the trial that I was working with while I worked at the University of Edinburgh; I was the Research Fellow involved in the qualitative study that was embedded in the RCT, looking at the experiences of patients and educators (nurses and dieticians) during the trial. Budget savings after I left meant that the team were also able to do a further qualitative piece of work looking at the close of the trial with the educators, which has also thrown up some really interesting findings.

The final report is titled “A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial”, and is published by Health Technology Assessment, 21(20). The link to the downloadable version of the report is here.

New article

I have somewhat neglected this blog of late, but hopefully will return to it more regularly soon. I am now back in clinical practice, working as a health visitor in central Scotland, although still interested in and looking to be involved in research.

In the meantime however, another article from the qualitative research project I was involved in at the University of Edinburgh has now been published, and so I am delighted to be able to provide a link to it:

Lawton J, Kirkham J, Rankin D, White DA, Elliott J, Jaap A, Smithson WH, Heller S. (2016) “Who gains clinical benefit from using insulin pump therapy? A qualitative study of the perceptions and views of health professionals involved in the REPOSE (Relative Effectiveness of Pumps over MDI and Structured Education) Trial”, Diabetic Medicine, 33(2): 243-251. Link to article.

I really enjoyed the interviews I did with the diabetes educators working on this trial, and am delighted that we have (thus far) published two articles from these interviews.  My grateful thanks to all who participated.

 

Our recent articles

I am getting ready to leave my post at the University of Edinburgh, as my contract is finally ending (I am very grateful to the funders and to the University that I was able to see the contract through its final few months, after having to take time out for maternity leave. I know that not all researchers on fixed-term contracts are so lucky). I do intend to keep up with this blog, although it will probably change focus a little as I will be returning to clinical practice, at least in the short term, although I am not abandoning academia entirely and still hope to write a bit here and there.

I did want to provide links, though, to a couple of articles that have been published recently from the qualitative work that I have been involved in. I haven’t written about the project up till now, and won’t go into detail as the trial is still ongoing (with final clinical and statistical data due to be collected later this year), but this article in BMJ Open by my colleagues outlines the REPOSE trial, the qualitative sub-study of which has been my work over the last nearly 3 years. REPOSE is a randomised controlled trial which is seeking to compare two types of treatment for Type 1 diabetes (multiple daily injections of insulin, or MDI, and insulin pumps) alongside structured education (the DAFNE – Dose Adjustment for Normal Eating – course) for both sets of patients. The qualitative study involved interviewing both patients and DAFNE educators about their experiences, with the hope that our findings can help with interpreting the final trial findings and add value to the overall trial outcome, as well as potentially influence good practice in both diabetes care and in clinical trials more generally.

The first qualitative article we published is in Diabetes Research and Clinical Practice, and is titled “Perceptions and experiences of using automated bolus advisors amongst people with type 1 diabetes: A longitudinal qualitative investigation”. This article is open access.

The second article, also open access, was published in Trials journal last month and quickly became highly accessed, something of which we are very proud, as clearly we have tapped into a very pertinent and important issue in trials work. The article is titled “Uncovering the emotional aspects of working on a clinical trial: a qualitative study of the experiences and views of staff involved in a type 1 diabetes trial”.

Thoughts on World Breastfeeding Week 2014

I have been on a bit of a blog hiatus; in November last year I gave birth to a beautiful baby and I have been experiencing the roller-coaster of parenthood ever since. I am still on maternity leave and hadn’t particularly intended on blogging while off work, but a couple of things have appeared in the media over the last week or so which started to get the rusty braincells stretching again. For this post I want to concentrate on World Breastfeeding Week 2014, which is this week.

I hadn’t particularly given awareness days/weeks/months any critical thought up till a couple of years ago, probably because I have not been particularly affected by the issues demanding awareness. However, I remember reading a blog piece (I think on Feministing although I can’t find the exact post now) one October about the onslaught of pink that Breast Cancer Awareness Month brings each year. This piece, from the perspective of a woman who (if I recall correctly) had had breast cancer herself, pointed out that for people like her, and her loved ones, they were all more than aware of breast cancer, that merely giving something a pink wrapper will change nothing, that buying pink products may make people feel they have ‘done their bit’ even though they don’t know where their money is being donated, or what proportion of their money is being donated, or whether the charities receiving the funds from the pink goods are focused on research, treatment and/or ‘awareness’. Not to mention the infantilising and gender-dubious nature of a lot of the pink products themselves. I also saw comments from a friend (now cancer-free) who talked about hating the annual promotion of ‘Race for Life’ as it was a constant reminder of the cancer she had experienced and could potentially face again. In addition I think that Dr Margaret McCartney’s concerns in the BMJ about the annual Movember campaign are a useful contribution to the debate about ‘awareness’ and what it is trying to achieve, as well as potentially unintended consequences: BMJ.

As a health visitor I was (and am) always totally committed to supporting breastfeeding. This year though I have the extra experience of being a mother, and not only that, but a mother who has had real struggles with breastfeeding. Without getting into too many personal details, I had poor milk supply from the beginning (I suspect a combination of medication I had to take antenatally till about 8 weeks postnatal, recovery from Caesarian section, stress and who knows what else) meaning that from day 2 I had to start mixed feeding. I have never ever felt guilty about this, as I know that it was the right thing to do for my daughter (watching your baby not thrive is not an experience I’d wish anybody). I have though, always felt so very disappointed – breastfeeding was the one thing I so so wanted to do and for it to go well, and it not going well still makes me really upset. It didn’t help that I beat myself up for it – as a health visitor I have supported I don’t know how many people with breastfeeding, including having mothers telling me they would have given up without my help; I have done the UNICEF Baby-Friendly training; I know what to do, and yet it just wasn’t happening for me. I had a ton of help and support from health professionals (and have to say that the staff at Forth Valley, both in the hospital and community, are an absolute credit to the NHS, I was so impressed with them) and also a breastfeeding support group which was, and remains, a lifeline. It seemed like the whole world had observed me feeding and thought that the positioning and attachment was fine, but even despite the supplementation with formula it took a few months before my daughter started putting on decent amounts of weight, which was a real worry. Although I never experienced problems like mastitis or thrush I did experience awful pain for the first few weeks, and all in all it has to be said that it was nothing like the beautiful Zen-like experience that I had hoped for and (if I’m honest) expected.

Eight and a half months later, against the odds, I am still doing some breastfeeding at each feed. I am also topping up with formula milk at each feed, but I am really proud of myself for getting this far and still giving some breastmilk (most of the people I have talked to have said that they would have given up long ago). I have though been doing a lot of thinking about the messages we send as health professionals about breastfeeding, and I hope that this experience will make me a better and more thoughtful (and critical) practitioner.

Checking out the World Breastfeeding Week tweets on twitter has been a bit depressing, I’ve thought. I appreciate that a 140-character medium isn’t going to be the best for subtle and nuanced consideration of the issues and the message is distilled down in the most part to ‘it’s wonderful, with the right support and correct positioning anyone can do it, breast is best’. But I had tons of support, from both health professionals and certified lactation consultants, got positioning and attachment right (bad habits crept in later, not least thanks to De Quervain’s tenosynovitis which meant that I had trouble bringing the baby to the breast and it is infinitely less painful to do it the other way round), I knew all the tricks in the book (having studied the damn book enough!) but it still just didn’t work the way it is always presented. I never had the sensation of my milk ‘coming in’ on day 3 (or at any point after that), I have never felt any sensation of milk ‘let-down’ at the start of a feed, I never managed to express more than a few mls at any one time (yet another disaster to make me feel even crappier!). In the worst first few weeks I looked up all I could about breastfeeding problems, and found a research paper on breastfeeding idealism which was basically the research project I would have loved to do if someone hadn’t already done it: Hoddinott et al 2012. This research talks about the gap between education messages about breastfeeding and the messy reality. More recently I read Burns et al 2012 which is about how midwives talk about breastfeeding and the effects of the language used. Both have got me thinking about how I could best as a practitioner support women who want to breastfeed without resorting to one-size-fits-all messages or trite soundbites. I think we do parents a great disservice by presenting breastfeeding as easy, natural and ‘best’ while denying that many women find it difficult, heartbreaking, painful and stressful. If nothing else, I really hope that my less-than-ideal experience with breastfeeding leads to me being more use to families I may work with in the future.

But what about breastfeeding awareness and World Breastfeeding Week? This piece by Hollie McNish is a reflection for World Breastfeeding Week on some of the reactions she got to her poem on breastfeeding going viral online earlier this year. I am lucky that I have never (to my knowledge) faced any disapproval for breastfeeding in public, but know that negative attitudes are still common. And while anyone thinks that it is acceptable to compare breastfeeding with sex or urination/defecation, or that breastfeeding will turn baby girls gay and baby boys sex-crazed, then yes absolutely we need breastfeeding awareness, and not just for one week a year. There is work to be done on so many fronts. Let’s just think about how we can do it in a way that doesn’t trivialise, or infantilise, or fetishize, this complex, beautiful, difficult, wonderful process.

On being paid to breastfeed

There’s been a fair bit of coverage today of this story that a trial is beginning in a couple of deprived areas of Yorkshire of paying new mothers up to £200 in shopping vouchers to try and encourage them to breastfeed for 6 months, with a view to extending the scheme if it proves successful. Breastfeeding is a subject currently high up in my consciousness, as I have just started maternity leave (no baby as yet though! 🙂 ) and do intend if possible to breastfeed if I can. I have really mixed feelings about this initiative.

In my last post I ranted about people constantly referring to breastfeeding as “free”. As I said there, it is only “free” in the sense that money doesn’t change hands the way it would if milk was bought and sold. The demands on a woman’s (and wider family’s) time, work, health, etc are not to be sniffed at, and there are plenty of economic implications. Breastfeeding doesn’t always work out quickly, sometimes it can take several weeks to get properly established, and in that time the woman might experience pain, stress, and complications requiring help from health staff and/or medication – all of which cost money (OK not to the woman directly, but they have to be paid for somehow and it is the health services that pick up the tab). Even if it does work out, for someone exclusively breastfeeding the physical costs of feeding every few hours day and night are not to be taken lightly. And on return to work, if you are still feeding whilst the baby is in childcare, there is a cost to the employer of providing facilities for expressing breastmilk (a private room and a fridge, as well as time).

So part of me kind of welcomes the monetary aspect of this – I don’t necessarily think it is a bad thing that the financial aspects of breastfeeding are explored and discussed. Having said that, I suspect that would be an unintentional outcome of the initiative – I don’t think the vouchers are there to extend the debate, just to simply act as an incentive. Incentives in themselves aren’t necessarily a bad thing – it would be great if breastfeeding rates could improve, and nationwide they appear to be quite stubbornly not growing currently. However, I am not convinced at all that this is the way to go.

I have a number of concerns. One particular red flag in the BBC article linked to above was the sentence “Midwives and health visitors will be asked to verify whether the women are breastfeeding.” It reminded me of the concerns that lecturers had/have in higher education about having to verify whether foreign students are attending lectures and reporting back; if we had wanted a police role we would have trained to be police officers, not nurses/lecturers. As it is, health visitors are often already seen as the breastfeeding police (and not in a good way! – I think a common perception is that we will bang on about breastfeeding regardless of whether the woman wants to continue or not, and are unsupportive to families who choose to formula feed), and I don’t think that this will particularly help the therapeutic relationship that we all strive to build with families. I want to offer support to families to feed in the way they choose, not police whether they are meeting the criteria for a particular benefit/incentive. Also, this scheme does nothing to address the gaps in service which might lead to women not being supported – yes by all means give vouchers, but if there are not enough appropriately trained health professionals to offer support when the going is tough, the vouchers aren’t going to solve breastfeeding issues.

There is also the class issue to consider – this initiative is currently aimed at a more deprived, lower socio-economic area, with the assumption appearing to be that money is therefore an appropriate incentive to offer. There are plenty of so-called working-class women who breastfeed, and plenty of affluent women who choose not to, and I worry that the use of monetary incentives in deprived areas could act in a way to stereotype further the people who live there. I think that it would be better to provide more funding to train more health professionals to high standards in the full range of infant feeding, for all families who want/need that support, and provide the ongoing support needed instead of simply being the Breastfeeding Police monitoring who’s claiming the money.