How blue spaces could play a part in making our cities healthier

AT Glasgow Caledonian University we have found evidence that living near a blue space can significantly reduce mental health conditions, with those living in the most vulnerable areas of our cities harvesting the largest benefit.

As a member of the University’s Green and Blue Space Wellbeing Research Group, I led a 10-year study centered around the 250-year-old Forth and Clyde Canal, which runs through some of the most deprived areas in North Glasgow. This was a retrospective study, analysing primary care health data routinely collected by the NHS for 10 years until 2018 involving 132,788 people. The canal has been under regeneration since the 2000s and is now a “smart canal” that uses technology to reduce flood risks and the impact of climate change. The canal regeneration has also produced a number of health benefits in the area.

Our study team found that living near the canal reduced the risk of mental health conditions derived from socio-economic deprivation by 6% for those in the highest risk category and 4% for those in the “medium deprivation” group. Although these effects may appear small at first sight, they can be game-changing from a population perspective.

People living in the most socio-economically deprived areas of our cities carry a disproportionate burden of the adversities caused by urbanisation, as climate change risk, socio-economic deprivation and mental health vulnerabilities tend to cluster. For instance, we also estimated the effect socio-economic deprivation has on the likelihood of developing a mental health condition. Our findings showed that those living in the most deprived areas of our study experienced up to 154% higher risk of mental health disorders than those in the least deprived areas. This is a tremendous increase which reflects the persistence of health inequalities in our societies and essentially a call for action.

Globally, as estimated by the World Health Organization, approximately one billion people lived with a mental health condition in 2020 and the United Nations have classified mental health as a “pressing development issue” in their Sustainable Development Goals (SDGs). There is currently more ongoing research towards the use blue spaces as therapeutic landscapes of mental health and the idea is rapidly emerging.

Earlier this year, using the same NHS datasets, we published a similar study which showed that living within 700m of a canal reduces the risk of cardiovascular disease, a stroke or hypertension for people in deprived areas by up to 15%. It also lowers the risk of diabetes by 12% and obesity by 10%.

These important findings highlight the role blue spaces could play in making our cities healthier and more sustainable. Our studies call for regeneration efforts to focus on the most deprived areas of our cities and provide evidence that blue spaces could be a powerful tool to reduce mental and general health inequalities in our society.

Our recent study “A population-based retrospective study of the modifying effect of urban blue space on the impact of socioeconomic deprivation on mental health” has been published in the Nature journal.

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Highland nurse blames care errors for avoidable sight loss

A RETIRED nurse left blind by a treatable eye condition has criticised medication blunders and diagnosis delays for her ordeal.

Dr Betty Farmer, 75, who lives alone in Inverness, now relies on friends for help after her eyesight was destroyed by Giant Cell Arteritis (GCA).

The condition, caused when arteries in the head become inflamed, requires urgent intervention but vision loss can usually be prevented with steroids if symptoms are recognised in time.

Dr Farmer, whose 40-year career spanned senior nursing posts in the NHS and academia, is now completely blind in her left eye and has only minimal vision her right.

She has lodged complaints about her care by NHS Fife and Highland with the Scottish Public Services Ombudsman, but was shocked when the watchdog said it would take around 11 months before it can even consider the case.

She wants more done to make at-risk patients and clinicians aware of the warning signs, adding: “My whole story is a perfect description of the terrible mess that NHS Scotland is in.

“It’s a bureaucratic mess. The staffing is awful, there’s no integration whatsoever, and there’s no services for people like me once we are blind.”

READ MORE: ‘Grim situation’ for NHS as doctors head abroad and junior medics quit for jobs in finance

Dr Farmer said she had been “disgustingly healthy and very independent” up until a diagnosis of rheumatoid arthritis seven years ago, where the immune system mistakenly attacks the joints causing painful swelling and stiffness.

During the pandemic she was switched from steroids to a biological therapy, Rituximab, which suppresses the immune system.

She has since learned that patients over 55 with autoimmune disorders who are also immunosuppressed are more susceptible to GCA, with one clinician said to have been “horrified” that she was not maintained on a precautionary dose of steroids at the same time.

Dr Farmer’s symptoms began in September 2021, when she was staying at a hotel in Fife while visiting her sister, who was terminally ill in a care home with Parkinson’s Disease.

“I woke up in the middle of the night with this terrible headache and pains all over my face and scalp – I thought my head was going to blow off,” said Dr Farmer.

“My throat was red and burning. Every vessel in my face and my head was on end.”

Betty Farmer from Inverness (Pic: Peter Jolly)Dr Betty Farmer lost her sight in the space of a few weeks after GCA symptoms developed

A Covid test was negative, but Dr Farmer noticed she was losing weight and began to experience difficulties chewing.

The main symptoms of GCA are frequent, severe headaches; pain and tenderness over the temples; jaw pain while eating or talking; and vision problems.

Flu-like symptoms and weight loss are also common.

However, when Dr Farmer later contacted her GP, she was prescribed penicillin and told to call back for a throat swab if the symptoms persisted after 10 days.

However, when she did – on October 15 – she discovered that the GP surgery was closed for a public holiday and, on the same day, received a call from her sister’s care home in Fife that her sister had “significantly deteriorated”. 

READ MORE: Dentists warn of ‘basic’ NHS service as funding cut looms

Dr Farmer rushed to Fife, but the headaches became more intense and she began to experience other symptoms – including difficulty swallowing and black spots in her vision.

She sought help from an optician. 

“He was horrified,” said Dr Farmer. “He took pictures and sent them immediately to the eye clinic. 

“He should probably have sent me straight to A&E, but supposedly there was a pathway in place. 

“I was told I’d be called in for an appointment the same day, but the call didn’t come.”

Guidelines stipulate that patients with suspected GCA who are experiencing vision problems should get a same-day appointment with an ophthalmologist at a hospital eye department.

But when Dr Farmer telephoned the eye clinic later that day she said was wrongly told that the doctor could not see her unless she registered with a GP in Fife first.

She finally got an appointment to see the consultant ophthalmologist the next day, but only after contacting the doctor’s medical secretary directly.

She said: “By this point I’d lost the sight in my left eye and most of the right eye. I’m left with grey shapes and shadows.

“When they [the consultant] saw the situation they said it was ‘classic GCA’. They were horrified to learn that I was on Rituximab with no steroid back up and immediately put me up on a steroid infusion.”

READ MORE: Scotland cancer wait times worst on record 

Dr Farmer was admitted as an emergency to the Victoria Hospital in Kirkcaldy where she spent three nights, but it was too late to save her sight.

“The day before I was discharged, my sister died,” said Dr Farmer.

“My sister was the kindest, loveliest person – she never, ever asked me for anything. Except: ‘don’t leave me alone when I die’. That’s hard to take.”

Betty Farmer from Inverness (Pic: Peter Jolly)Dr Farmer was finally admitted to the Victoria Hospital in Kirkcaldy in October last year, but it was too late to save her sight

Dr Farmer said she is “utterly convinced”, after speaking to doctors, that the change in rheumatology medication led to the onset of her GCA – an error compounded by the delays in diagnosing and treating the condition.

While her own GP surgery quickly carried out a serious case review , she felt that her concerns were “brushed off” by the health boards – leading her to escalate her complaints to the SPSO.

She has also been left frustrated that her calls to issue leaflets about GCA to doctors and patients has been rejected.

Dr Farmer said: “They say GCA is rare – but it’s not rare, it’s underreported.

“There are five groups in Scotland in each of the big cities with members who have all suffered and continue to suffer.

“I’m not interested in money or compensation – I never wanted to go public.

“I’m not interested in anything except stopping someone else going blind, and for that you’ve got to give people the information.

“Sudden blindness is horrific – I’d sooner lose an arm than go through this, but it’s avoidable and it can happen to anyone, especially if they’re over-55 and immuno-suppressed.

“If they had told me I might be susceptible to this and ‘here’s the symptoms’, none of this would have happened. In my case I was treated for a sore throat when that was the least of my problems.”

READ MORE: Blind man suffers life threatening injuries after Glasgow subway fall

A spokesman for NHS Highland said: “We are sorry that the patient feels the level of care provided is not what she would have expected.

“We cannot comment on individual cases and we will work closely with the SPSO to review this case in more detail if required.”

Janette Owens, director of nursing for NHS Fife, said: “We are unable to comment on the care of individual people for reasons of patient confidentiality.

“We can confirm, however, that our Patient Relations Team remain in dialogue with the individual to discuss their concerns fully.”

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Life expectancy, excess deaths, and lessons for Scotland

LIFE expectancy in Scotland is falling and the number of people dying over the past six months has been 10 per cent higher than average.

It is hard to find two statistics that better sum up the grim reality of our downward spiral in population health.

The former is often misunderstood as a prediction for how long someone born today will live.

In reality, what life expectancy does to offer a snapshot of the prevailing conditions on mortality of the time – from healthcare to deprivation – and project what longevity would be if nothing changed.

For example, someone born in the UK 100 years ago, before childhood vaccinations and free universal healthcare, would have had much better life expectancy by the age 40 than they had had at birth.

READ MORE: What can Scotland learn from Ireland’s surge in life expectancy?

Until relatively recently, a steady growth in life expectancy was the norm. Between 1981 and 2011, males in Scotland added more than seven years to their life expectancy; females, more than five.

Then things stalled.

Between 2012 and 2019, male and female life expectancy at birth increased by just 146 days – or an extra three weeks per year.

Average life expectancy in Scotland has been stagnating for a decade and is now in decline, but trends in Ireland have been starkly differentLife expectancy at birth in Scotland has been slowing and is now in decline Source: National Records of Scotland

In 2020, as the Covid pandemic hit, it fell sharply for both sexes for the first time – a measure largely of the thousands of lives lost to the virus, and our failure to contain it.

By 2020, life expectancy for males in Scotland – at 76.1 – was actually lower than it had been a decade earlier.

The question is what happens now?

The first thing worth noting is that the stagnation of the past decade, long before Covid hit, was not inevitable. You only have to look to the Republic of Ireland to see that.

The UK’s nearest neighbour, culturally and geographically, now has the highest life expectancy in Europe for males (the UK ranks 16th; Scotland on its own 19th).

Between 2009 and 2019, Ireland added three years to male life expectancy at birth, continuing the trends of the previous 20 years (Ireland added 6.1 years males life expectancy between 1989 and 2009). In 2020, it stayed the same.

READ MORE: More than half of Scotland’s excess deaths caused by non-Covid illnesses for first time since start of pandemic

Unlike the UK, Ireland has no NHS – but it does have slightly more doctors and hospital beds per head, more CT scanners, and higher health spending, with the poorest third of the population still entitled to free healthcare.

Both countries were badly hit by the credit crunch, but their responses differed.

Ireland reduced some healthcare provision, welfare benefits for parents and young people, and eduction spending, but – as Professor Richard Layte, a sociologist and health researcher at Trinity College Dublin puts it – “none of the reductions that happened in Ireland were savage to the point where those services stopped running”.

Average life expectancy in Scotland has been stagnating for a decade and is now in decline, but trends in Ireland have been starkly different

Average life expectancy in Scotland has been stagnating for a decade and is now in decline, but trends in Ireland have been starkly differentLife expectancy for males and females in Scotland is below the UK average and in line with Eastern European nations, rather than Western Europe (Source: NRS)

Evidence from other nations which pursued savage austerity measures, such as Greece, show a corresponding increase in mortality.

In Scotland, the UK Government policies had a disproportionate effect because higher levels of deprivation and chronic disease here mean that a larger share of the population relies on social security and healthcare benefits.

“That leads to a population who are more risk when things do go badly,” said Dr Gerry McCartney, a public health expert who has previously spoken to the Herald about the trends.

In an optimistic scenario, the fact that Covid is diminishing in its lethality thanks mainly to vaccines, antivirals and other drug treatments, might have meant that 2020’s fall in life expectancy would be quickly reversed.

READ MORE: The Scottish NHS is collapsing – are doctors right to blame the SNP?

Unfortunately, a toxic combination of a crumbling NHS, cost of living emergency, and the looming threat of recession suggest that the prospects for a sudden turnaround are slim to, frankly, nil. If anything, worse is probably to come.

Losing your job, for example, is associated with a staggering 63% increase in premature mortality risk.

Meanwhile, the Office for National Statistics said this week that 18% of 50 to 65-year-olds who have left the UK workforce since the beginning of the pandemic, and not returned, are on an NHS waiting list for elective treatment.

Average life expectancy in Scotland has been stagnating for a decade and is now in decline, but trends in Ireland have been starkly differentSource: Private Healthcare Information Network

Unsurprising then that demand for private healthcare is growing – something only likely accelerate the already widening gap in life expectancy between rich and poor.

In Scotland, the number of people self-funding their own operations has climbed by 72%, from 2,850 in January to March 2019 to 4,900 in the first quarter of 2022. Only Wales and the East Midlands have seen faster growth. Hip and knee replacements, hernia repairs, and cataracts surgery top the list.

Despite Covid fading as a direct cause of death, excess mortality remains stubbornly high.

In the six months to September 25, just 41% of Scotland’s excess deaths had Covid as the primary cause compared to 81% in 2021.

READ MORE: Fewer operations on NHS Scotland in 2022 than a year ago despite ‘recovery’ agenda

Nonetheless, excess mortality as a whole has not declined: it continues to run at 10% above the five-year average, just as it did last year (notably, statisticians compare 2022 mortality against 2016-19 plus 2021, while 2021 is compared against 2015-19; 2020 is excluded as an anomaly. However, if 2022 were compared against 2015-19 instead, excess mortality would be even higher).

The bottom line is that thousands more people are dying from all causes – 2,716 since mid-March alone – than can be considered “normal”.

Average life expectancy in Scotland has been stagnating for a decade and is now in decline, but trends in Ireland have been starkly differentSince the beginning of the pandemic, the UK has recorded a total of 2,370 excess deaths per million population compared to 809 per million in Ireland (Source: Our World in Data)

National Records of Scotland has said there “does not appear to be a single factor behind this increase”, with their analysis showing an uptick “across a wide range of illnesses and other causes”. Among them were 46 infant deaths – an increase of 12% on the five-year average.

Many hundreds will be linked to logjammed A&E departments, where it is already known that patients who spend six to eight hours waiting to be transferred to a hospital bed are more likely to die in the subsequent 30 days. In July alone, nearly 4,500 spent over 12 hours in A&E.

With warnings of a “twindemic” of Covid and flu this winter, the statistics in the short-term will only get grimmer.

In longer-term though, we should look to Ireland and ask what we can, and should, be doing differently.

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Scots GP says addiction should form part of university curriculum

Michael Blackmore likens becoming a doctor to being, “given the keys to the sweetie jar.”

The Scottish-based GP battled drug and alcohol dependency for 20 years after leaving medical school, his coping mechanism for the “uncertainty of medicine”.

Now recovered, he says his experiences left him better equipped to help those in the grip of addiction. He believes student doctors should receive more training in this area at university, including hearing from those directly affected.

Recovery groups in Glasgow say a more empathetic and informed approach from GPs could help make in-roads into Scotland’s drug death toll.

There is still, they say, too much focus in general practice on “treating drugs with drugs”.

GPs are sometimes people pleasers 

Like many students, Dr Blackmore says he spent his evenings “kicking the arse out of alcohol and recreational drugs”.

“It then developed in medicine and then I had keys to the sweetie jar,” he says.

“The uncertainty of medicine was too much to handle at times and I developed an addiction and crashed and burned.”

After receiving help he retrained to work as a GP with a specialist interest in addictions working for the Scottish Prison Service and is now a GP partner in Forth Valley.

GPs and drug recovery groups say addiction should form part of the university curriculum for trainee doctorsDr Michael Blackmore

He was among those taking part in an event this week at the University of Glasgow this week where students heard from 25 people with lived experience of addiction, including acclaimed author and social commentator Darren McGarvey.

“I’ve got a small cohort of alcoholics and addicts and one of my ex-patients is here today, in recovery” he said.

READ MORE: Suspected drug deaths in Scotland 22% lower than last year 

“There is so much wrong in GP practice, there’s a massive recruitment and retention crisis, not enough GPs to go round and sometimes when you have a patient in front of you, it can be easy to do the quickest thing, give them a Valium prescription, Pregabalin, Tramadol etc,” added Dr Blackmore.

“GPs are sometimes people pleasers and it’s easier to get the patient out because you are worried about being behind. 

“The harder thing is to try to work out what is going on and how best to help them. I use our community link worker a lot – that’s a new thing the Scottish Government have put in place – and he can point them to services and that’s helpful.

“Doctors need more training in addiction. It should be part of the curriculum because people not only misuse alcohol and drugs but also food, gambling, sexual behaviour, the internet, gaming.”

GPs and drug recovery groups say addiction should form part of the university curriculum for trainee doctorsDr Michael Blackmore

He believes better training could have a “massive impact” on drug deaths.

“If there is more awareness about maybe not prescribing what people are demanding at the time, maybe reducing opioid prescribing, the Benzodiazepine prescribing then there wouldn’t be those drugs out in the community which adds to the polypharmacy drug-related deaths.”

READ MORE: Scotland’s poorest 15.3 times more likely to die from drug misuse

One woman who took part in the workshop and is now in recovery from drug and alcohol addiction, said: “To me, doctors just give you drugs for drugs.

GPs and drug recovery groups say addiction should form part of the university curriculum for trainee doctorsAgency

“My doctor never really challenged me on it. It was ‘maybe you are bipolar’ maybe you are something else.

“It did get to the point where I thought I was crackers. They don’t know how to help you. All I needed was another addict to listen to me.”

Darren McGarvey, Orwell Prize-winning author of Poverty Safari, told of his own experiences of GP consultations in the grip of alcoholism in his mid-20s.

He said: “I remember turning up at doctors and they were dishing out Diazepam like sweeties and dishing out anti-depressants like confetti.

GPs and drug recovery groups say addiction should form part of the university curriculum for trainee doctorsNewsquest

“You learned the steps of the dance and you learned what you had to say to get the drug you were looking for.

“For me -what an addiction is – is that under a certain emotional discomfort the idea arises in my mind that I would like to use something to take the stress away.

READ MORE: Steve Rick: It’s timeto turn technology on Scotland’s silent scourge 

“The problem I have, unlike other people who can enjoy alcohol or drugs in a responsible way is that once I start, things go out of control pretty quickly.

“When you take the drink and drugs away, the problem really presents itself which is a human being who does not know how to cope with stress. It’s a chronic illness but it can be arrested.”

The turning point for him, he says, was being told by another in recovery, “you don’t need to pick up another drink again.”

“I got sober in community centres, run-down church halls. Coffee, tea and a bunch of people who said: “I’ve been where you are, have you tried this.”

Allan Houston, a senior addiction worker in Glasgow with 29 years of experience, said of today’s event that it was helpful for those with addictions to hear that it’s “not just people from council estates” who are affected.

Doctors have a 10-12% lifetime risk.

He said: “After one of our sessions a student left in tears and said she had learned more about addiction recovery in one-and-a-half hours than a full five years of studying.

“Hopefully [this] is a start to getting it recognised that this is an important part of the curriculum in universities. There were 1333 drugs drug deaths in Scotland this year.

“We are talking about future GPs who are going to be working in the community and in hospitals. A lot of the people they see will have alcohol or drug issues.”

His recovery groups take many referrals from GPs now and he says the Scottish Government is making progress but called for more investment in rehabilitation for those coming through detox. 

“We are not there yet,” said Mr Houston. “People still turn up and they can’t get access to rehab.

“People need immediate help when they are asking for it. 

“We work with people who were put on a prescription 20 years ago and they are still on it. For me personally, that is abuse.

“Some people might need to stay on it for a long time and I’ve very pro harm reduction but there needs to be a pathway.”

The workshop was part of a broader movement called Humanising Healthcare and was organised by final year student Hugo Jobst. Feedback will be given to the Scottish Government and a similar event is planned at Dundee University for psychiatry students.

Dasha Romanyuc, a fourth year student from Russia, said addiction was covered by a “few lectures in second year.”

She said: ” It doesn’t really give you the personal side to it people feel and how you can help?”

Another GP, who took part, said: “Medical students have a wide knowledge base that can be learnt from books but to be compassionate and effective doctors they need to learn other skills too like listening, empathy and honest communication. 

“Meeting people with lived experience of addictions and learning from them in an interactive session is more memorable, authentic and impactful.”

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