Wednesday, 30 August 2017

PFIs bleeding NHS - time to buy them out

The independent Centre for Health and the Public Interest (CHPI) has today released a devastating analysis of accounts showing how PFIs are bleeding money from the NHS, and calls for public sector loans to be used to buy-out PFI contracts.

Over the past 6 years, companies which run PFI contracts to build and run NHS hospitals and other facilities have made staggering pre-tax profits of £831m – money which has thereby not been available for patient care over this period.

The findings show that If the NHS had not been paying profits on PFI schemes, deficits in NHS hospitals would have been reduced by a quarter over this 6 year period.

Over the next 5 years, almost £1bn of taxpayer funds (£973m) will go to PFI companies in the form of pre-tax profits – equivalent to a quarter (22%) of the additional amount of money (£4.5bn) that the government has promised the NHS over this period.

A number of PFI schemes are generating particularly high pre-tax profits for their operators. The company which holds the contract for the hospital at University College London has made pre-tax profits of £190m over the past 11 years. This is out of £527m paid to the company by the NHS. The total value of the hospital is £292m.

A small number of companies are bleeding the NHS of much needed funds.

The report finds that only 8 companies own or have equity stakes in 92% of all the companies holding PFI contracts with the NHS – meaning that there is very little competition between the companies bidding to build and run NHS PFI hospitals.

The report calls for public sector funding buy-out PFI contracts. It also recommends taxing PFI companies to recoup some of the profits which have been made and capping the amount of profit which can be made by a private company which has an exclusive public-sector contract with the NHS.

The report also calls for greater transparency of equity sales to prevent the unnoticed consolidation of market power by a small number of investors and renegotiation of contracts with the private companies to reduce the amounts the NHS has to pay.

Commenting today on the report, Dr Chaand Nagpaul, BMA council chair, said:

“NHS providers and commissioners are being pushed to breaking point because of unprecedented financial pressures so it is outrageous to see over £800m of much needed money being leaked out to private companies for profit alone.

“Private Finance Initiatives are an extortionate drain on the public purse, with private companies scandalously gaining at the expense of taxpayers and patients. The government should instead be properly funding new NHS capital projects to ensure money remains in the NHS in the long term. Ideally the government would either renegotiate lucrative PFI contracts or enable existing PFI schemes to be bought out by the NHS so that vital resources are available for frontline patient care.

“Looking more broadly at the role of private and independent providers in the NHS, a trend is emerging - independent sector provision of NHS healthcare has increased every year for the past five years. More attention needs to be paid to whether it provides."

See also Devestating NHS cuts 'shrouded in secrecy'

Monday, 7 August 2017

A revolution in speech animation?

I have always been fascinated by animated characters.  We know there is more to speech than simply words.  Facial expression adds significantly to our understanding.  As a deaf person I also know too well how precise movement of the lips and face help in my understanding of the spoken word. 

Forming speech is complex. About a hundred different muscles in the chest, neck, jaw, tongue, and lips must work together in forming speech. Every word or short phrase that is physically spoken is followed by its own unique arrangement of muscle movements.   No wonder then that animations can often appear flat and characterless. 

New research from the University of East Anglia (UK) could revolutionise the way that animated characters deliver their lines.

Animating the speech of characters such as Elsa and Mowgli has been both time-consuming and costly. But now computer programmers have identified a way of creating natural-looking animated speech that can be generated in real-time as voice actors deliver their lines.

The discovery was unveiled in Los Angeles at the world’s largest computer graphics conference - Siggraph 2017. This work is a collaboration which includes UEA, Caltech and Carnegie Mellon University

Researchers show how a ‘deep learning’ approach – using artificial neural networks – can generate natural-looking real-time animated speech.

As well as automatically generating lip sync for English speaking actors, the new software also animates singing and can be adapted for foreign languages. The online video games industry could also benefit from the research – with characters delivering their lines on-the-fly with much more realism than is currently possible – and it could also be it can be used to animate avatars in virtual reality.

A central focus for the work has been to develop software which can be seamlessly integrated into existing production pipelines, and which is easy to edit.

Lead researcher Dr Sarah Taylor, from UEA’s School of Computing Sciences, said: “Realistic speech animation is essential for effective character animation. Done badly, it can be distracting and lead to a box office flop.

“Doing it well however is both time consuming and costly as it has to be manually produced by a skilled animator. Our goal is to automatically generate production-quality animated speech for any style of character, given only audio speech as an input.”

The team’s approach involves ‘training’ a computer to take spoken words from a voice actor, predict the mouth shape needed, and animate a character to lip sync the speech.

This is done by first recording audio and video of a reference speaker reciting a collection of more than 2500 phonetically diverse sentences. Their face is tracked to create a ‘reference face’ animation model.

The audio is then transcribed into speech sounds using off-the-shelf speech recognition software.

This collected information can then be used to generate a model that is able to animate the reference face from a frame-by-frame sequence of phonemes. This animation can then be transferred to a CG character in real-time.

‘Training’ the model takes just a couple of hours. Dr Taylor said: “What we are doing is translating audio speech into a phonetic representation, and then into realistic animated speech.”

The method has so far been tested against sentences from a range of different speakers. The research team also undertook a subjective evaluation in which viewers rated how natural the animated speech looked.

Dr Taylor said: “Our approach only requires off-the-shelf speech recognition software, which automatically converts any spoken audio into the corresponding phonetic description. Our automatic speech animation therefore works for any input speaker, for any style of speech and can even work in other languages.

“Our results so far show that our approach achieves state-of-the-art performance in visual speech animation. The real beauty is that it is very straightforward to use, and easy to edit and stylise the animation using standard production editing software.”

Thursday, 3 August 2017

Could disability awareness end supernatural myth-making in Africa?

Many people in rural African communities still believe that disability is caused by supernatural forces, curses and as ‘punishment’ for wrongdoings – according to University of East Anglia research (UEA, UK). 



The resultant stigma leaves disabled people vulnerable to neglect and abuse - with sexual abuse reported by 90 per cent of people with learning difficulties.

Many disabled children are kept ‘locked up’ at home – often for their own safety. But the more that communities come into contact with disability, the more awareness and understanding grows.

Meanwhile medical explanations for disability are beginning to emerge, with increasing numbers of families seeking medical advice for children with disabilities rather than consulting a witchdoctor.

The ‘Preparation of Communities: Using personal narratives to affect attitudes to disability in Kilifi, Kenya (Pre-Call)’ project was set up to promote disability awareness in small communities in a rural part of Kenya, by encouraging a process of reflection and education.

The research team at the Kenya Medical Research Institute (KEMRI) led focus groups to find out how cultural beliefs and knowledge shape people’s understanding of disability.

The discussions involved 21 community groups located across the five constituencies of Kilifi County, bordered one side by the Indian Ocean coast and stretching into the rural interior. A total of 263 participants were involved who observed Christianity (70 per cent), traditional religious practices (20 per cent) and Islam (10 per cent).

Lead researcher Dr Karen Bunning, from UEA’s School of Health Sciences, said: “Information on the medical causes of childhood disability are not widely available across communities in low-income countries and understanding is generally poor.

“In Namibia for example albinism is explained by the mother having sex with a white man or a ghost. And in Guinea-Bissau, epilepsy is widely thought of as being caused by evil spirits, or sometimes as a punishment for wrongdoing.

“We found that disability is often explained by things like extra marital affairs invoking a curse, witchcraft, supernatural forces such as demons or ghosts affecting the child, and the will of God.

“Curvature of the spine or limbs represented the effects of a curse, saliva production was linked to demons and ill-gotten financial gain.

“The different explanations represent a real mixture of traditional, religious and biomedical beliefs,” she added. “And while biomedical factors such as inherited conditions or antenatal care were increasingly talked about, these explanations did not negate other culturally-based accounts.”

The findings reveal that underpinning all of these explanations is a desire to make sense of disability and, particularly for carers, to improve the given situation. And where an explanation of wrongdoing or the presence of an evil force might result in a visit to a local witchdoctor, a medical attribution might be followed with a visit to a medical centre.

The project also looked at the challenges faced by people with disabilities and their carers.

Dr Bunning said: “What tends to happen is that these types of cultural beliefs affect how individuals with disabilities view themselves and how other people see them. Attributing the child’s condition to some form of malevolent preternatural force by reference to demons, evil spirits and witchcraft contributes to the view of disability as both undesirable and unacceptable.

“People with disabilities in Africa have poor access to health provision, low school attendance, limited employment rates and low wages. More extreme consequences include neglect and abuse – with sexual abuse reported to occur at some time in the lives of 90 per cent of the population with learning difficulties. People with communication difficulties are at a high level of risk because they are less able to report abuse.

“We found that children with disabilities are often kept apart from the local community in restricted environments – contributing to the social distance between them. Although in many cases this is to protect them from abuse and keep them safe.

“The burden of caring for family members with disabilities also led to discrimination by association,” she added. “And the stigma associated with people with disabilities is so great that it also extends to anyone trying to help. The implication being that anyone offering help would also give birth to a disabled child.

“But we found that the more people come into contact with disability, the better their understanding. Real life encounters with people who have disabilities can be a really positive step, so raising disability awareness in small communities can really help.”

‘The perception of disability by community groups: Stories of local understanding, beliefs and challenges in a rural part of Kenya’ is published in PLOS ONE on August 3, 2017 . The research was led by UEA (UK) in collaboration with the Kenya Medical Research Institute (Kenya), the University of Oxford (UK) and the London School of Hygiene and Tropical Medicine (UK).

Friday, 28 July 2017

Devestating NHS cuts 'shrouded in secrecy'

Doctors warn new plans for severe NHS cuts are 'shrouded in secrecy' and will ‘cause uproar’

Health service leaders have refused to publish details of plans for severe cuts that could extend waiting times, reduce access to services, cut down on prescriptions and treatments, and even merge or close hospitals and facilities.

The Capped Expenditure Process (CEP) was introduced in April 2017 and instructs NHS commissioners and providers in 13 areas across England with the largest budget deficits to make considerable cuts in order to achieve financial balance by next April1.

The areas affected by the CEP are under intense pressure to drastically reduce spending by around £500m, and health leaders have been told to ‘think the unthinkable’ with regards to cuts.

The 13 areas involved have submitted plans and NHS England chief executive Simon Stevens has now told commissioners and managers to get on with delivering the proposals – warning that more ‘difficult choices’ are on the way.

The BMA sent Freedom of Information requests to NHS Improvement and each of the 13 areas, requesting the proposal documents. NHS Improvement said the documents belong to local health authorities and suggested requests were forwarded to those organisations.

The BMA then wrote to organisations in each of the areas requesting the final return – or the details within if not the whole documents. Representatives from just eight of the 13 areas responded and none provided the full document or any significant details of their plan.

The BMA says it is deeply concerned by the CEP, the secretive manner in which plans have been drawn up, and the risk that proposed cuts to already stretched services will have to patient care and NHS staff. Only limited details about proposals have been made available, typically by individual trusts and CCGs, or through leaks in the media.

Senior NHS leaders involved in drawing up local plans have told the BMA that even the more modest of the proposals ‘would cause uproar’ and that they are frustrated by the ‘ridiculous’ pace and secrecy of the process. One said he felt local leaders were being bullied.

Commenting, BMA council deputy chair, Dr David Wrigley, said today:

“These plans could have serious consequences for doctors working on the frontline and for the care and treatment patients receive and can expect in hospitals and GP surgeries in these areas.

“It is bad enough that brutal cuts could threaten the services but it is totally unacceptable that proposals of this scale, which would affect large numbers of patients, are shrouded in such secrecy.

“Patients, the public and frontline staff – who have worked so hard to keep the health service afloat through years of underfunding in the face of rising demand – must be at the heart of any plans for the future of the health service but we are all frozen out of discussions, and local health managers are being asked to push forward despite being unwilling to share their decisions openly.

“This government must stop and think before pressing ahead, as cuts on this scale in this timeframe would have a devastating impact on patients and staff. Our NHS is one of the very best healthcare services in the world, with hugely talented staff but it relies too much on the goodwill of the staff who dedicate their lives to helping patients. This simply cannot go on. The government must provide adequate funding for the health service before it is too late.”

Speaking anonymously to the BMA, one trust chair with oversight of the process of drawing up the plans in his area, said:

"We were descended on and asked to think the unthinkable in no time at all. The NHS seems to go into a zone of secrecy as an automatic reaction. That’s the thing that really upsets me – the secrecy of it all and the ridiculous pace in which solutions are to be crafted and agreed. It’s the management culture too – it’s all hierarchical power and bullying. Even the most modest proposals would cause uproar.”

Tuesday, 25 July 2017

Will farm animal welfare be sacrificed post Brexit?



Are UK farm animal welfare standards at risk in post Brexit trade deals?



A parliamentary sub-committee warns of the potential fall in standards unless farm animal welfare is a key part of any post Brexit trade deals, particularly because many other countries have lower standards than in the UK, and in the rush for trade deals these may be sacrificed.    

The EU Energy and Environment Sub-Committee today publishes its report on Brexit: farm animal welfare. 

The UK currently has some of the highest farm animal welfare standards in the world and there is cross-sector support for maintaining those high standards after Brexit.

The greatest threat to farm animal welfare standards post-Brexit would come from UK farmers competing against cheap, imported food from countries that produce with lower standards than in the  the UK. 

The sub-Committee warns that the Government's wish for the UK to become a global leader in free trade is not necessarily compatible with its desire to maintain high animal welfare standards.

The demand for high-welfare products is ultimately driven by whether consumers prioritise purchasing those products despite the  added cost, rather than buying cheaper, lower-welfare products.

The Committee found that consumers are not always aware of the difference between production systems or willing to pay a higher price for premium welfare products. This could exacerbate the challenge to UK farmers' competitiveness arising from a potential increase in cheaper imports produced to lower welfare standards.

The report also found there is an overwhelming reliance on non-UK EU citizens to fill crucial official veterinary positions in the UK. 

The Committee calls on the Government to ensure that the industry is able to retain or recruit qualified staff to fill these roles post-Brexit.

Chair of the EU Energy and Environment Sub-Committee, Lord Teverson said:

"The UK has some of the highest farm animal welfare standards in the world and UK producers are rightly proud of those. We see no reason why Brexit should diminish those, as long as the Government is aware of the challenges ahead and acts accordingly.

"We heard evidence of undeniable concern that opening up the UK market to free global trade poses a number of issues. As we said in our last report, Brexit: agriculture, the Government may find it hard to reconcile its free trade ambitions with its commendable desire for preserving high farm animal welfare standards.

"We heard overwhelming support for farm animal welfare standards to be maintained or improved. To help achieve that, we urge the Government to secure the inclusion of high farm animal welfare standards in any free trade agreements it negotiates after Brexit.

"Whilst Brexit provides the UK with the unique opportunity to review and potentially improve farm animal welfare standards, the Government will need to consider the effect of increasing standards on the competitiveness of UK producers as well the future trading relationship with the EU."

The committee also warns of a shortage of veterinarians.

Veterinarians play a key role in ensuring and inspecting farm animal health and welfare in the UK from farm to abattoir. They also play an important role in certifying animals in the context of trade. 

The committee note the overwhelming reliance on non-UK EU citizens to fill crucial official veterinary positions in the UK, and call on the Government to ensure that the industry is able to retain or recruit qualified staff to fill these roles post-Brexit.


Monday, 24 July 2017

Keep walking the Dog

Dog walking could be key to ensuring activity in later life



A new study has shown that regularly walking a dog boosts levels of physical activity in older people, especially during the winter.

Published in the Journal of Epidemiology and Community Health, the study used data from the EPIC Norfolk cohort study, which is tracking the health and wellbeing of thousands of residents of the English county of Norfolk. 

The researchers from the University of East Anglia (UEA) and Centre for Diet and Activity Research (CEDAR) at the University of Cambridge found that owning or walking a dog was one of the most effective ways to beat the usual decline in later-life activity, even combatting the effects of bad weather.

Dog owners were sedentary for 30 minutes less per day, on average.

More than 3000 older-adults participating in the study were asked if they owned a dog and if they walked one. They also wore an accelerometer, a small electronic device that constantly measured their physical activity level over a seven-day period. 

As bad weather and short days are known to be one of the biggest barriers to staying active outdoors, the researchers linked this data to the weather conditions experienced and sunrise and sunset times on each day of the study. 

Lead author of the paper, Dr Yu-Tzu Wu from University of Cambridge, said “We know that physical activity levels decline as we age, but we’re less sure about the most effective things we can do to help people maintain their activity as they get older.

“We found that dog walkers were much more physically active and spent less time sitting overall. We expected this, but when we looked at how the amount of physical activity participants undertook each day varied by weather conditions, we were really surprised at the size of the differences between those who walked dogs and the rest of the study participants.”

The team found that on shorter days and those that were colder and wetter, all participants tended to be less physically active and spent more time sitting. Yet dog walkers were much less impacted by these poor conditions. 

Project lead Prof Andy Jones from UEA's Norwich School of Medicine said: “We were amazed to find that dog walkers were on average more physically active and spent less time sitting on the coldest, wettest, and darkest days than non-dog owners were on long, sunny, and warm summer days. The size of the difference we observed between these groups was much larger than we typically find for interventions such as group physical activity sessions that are often used to help people remain active.”

The researchers caution against recommending everyone owns a dog, as not everyone is able to look after a pet, but they suggest these findings point to new directions for programmes to support activity. 

Prof Jones said: “Physical activity interventions typically try and support people to be active by focussing on the benefits to themselves, but dog walking is also driven by the needs of the animal. Being driven by something other than our own needs might be a really potent motivator and we need to find ways of tapping into it when designing exercise interventions in the future.”

‘Dog ownership supports the maintenance of physical activity during poor weather in older English adults: cross-sectional results from the EPIC Norfolk cohort’ is published in the Journal of Epidemiology and Community Health. 

Time to act on price of alcohol?

Is it time to enforce minimum unit pricing for alcohol in the United Kingdom? The latest evidence provides further impetus to those campaigning to limit the sale of alcoholic drinks.

Alcohol misuse is the biggest risk factor for death, ill-health and disability among 15-49 year-olds in the UK, and the fifth biggest risk factor across all ages, and alcohol related problems are estimated to cost the NHS around £3.5 billion annually. In 2015, there were over 8,000 casualties of drink driving accidents in the UK including 220 fatalities and 1,160 serious injuries. Alcohol kills. So does price matter?

Alcohol is now 60% more affordable than it was in the 1980s, particularly because of big discounting of price in the major supermarkets.

Responding to the latest findings that almost 63,000 people in England will die over the next five years due to alcohol misuse, Professor Dame Parveen Kumar, BMA board of science chair, said:

“The BMA has repeatedly called for the introduction of minimum unit pricing across the UK – a call that is all the more urgent as 35 people a day in England are expected to die from alcohol misuse in the next five years.

“Minimum unit pricing in Canada has already seen a significant reduction in wholly alcohol related deaths. Time and again, it has been decisive, if overdue, action by successive governments, such as the public smoking ban, that has had more impact than a single doctor can have in a lifetime.

“While minimum pricing alone won’t solve all alcohol misuse problems, combined with work on education, marketing and the availability of alcohol, it will play an important role in reducing alcohol related harm and the financial burden this places on an already overstretched NHS.”

A 2008 model produced by the University of Sheffield suggested that a high enough minimum price could significantly reduce the impact and cost of alcohol to society. They also argued that drinking behaviour could be profoundly influenced by price as problem drinkers seek out the cheapest drinks.

The evidence that alcohol consumption goes down when price goes up is fairly strong, and government health advisers have concluded that ministers should introduce minimum unit pricing. In their report published last year the concluded:

“Policies that reduce the affordability of alcohol are the most effective, and cost-effective, approaches to prevention and health improvement … Implementing an MUP [minimum unit price] is a highly targeted measure which ensures any resulting price increases are passed on to the consumer, improving the health of the heaviest drinkers who experience the greatest amount of harm. MUP would have a negligible impact on moderate drinkers and the price of alcohol sold in pubs, bars and restaurants.”

The previous coalition government originally committed to implementing minimum unit pricing, but this has since been dropped. The alcohol industry and the supermarkets form a powerful lobby. But the promise to introduce minimum pricing was welcomed by Tesco because its own survey had found excessive drinking and the anti-social behaviour it causes is one of the public's most serious concerns. It was also backed by the British Liver Trust.

Then Health Secretary Andrew Lansley welcomed Tesco's "swift decision" to support introduction of MUP, saying:

"There is a vast social and financial cost attached to irresponsible drinking. We need to tackle not only issues of supply but also the behavioural drivers that lead to irresponsible behaviour".

There are of course arguments on all sides of the issue. It is a balanced choice. The consideration is whether the benefits of MUP outweigh any concerns. Some point out that alcohol is not a 'disease' of the poor, and price isn't the only factor. That is certainly true. Most adults in the UK consume alcohol and its use both influences, and is influenced by, social and cultural norms.

As a report published last year by the Centre for Public Health points out "there are no figures available to determine what proportion of the estimated 13 million adults who live in poverty overlap with the categories of problem drinkers". Nevertheless it concludes that interventions that target price are likely to have the greatest impact on national consumption and reduction in alcohol related harms.

It is no doubt one of those issues that get kicked around because of 'insufficient evidence'. This was also said repeatedly by the tobacco lobby when concern was raised about smoking and health. It took decades before effective action was taken on cigarette sales, and while that debate went on more people died necessarily from smoking related cancers and cardiovascular disease.











Sunday, 23 July 2017

Difficult ethical issues in Charlie Gard case

The news of death threats sent to staff at Great Ormond Street Hospital is disturbing. Whatever the opinion held on the issues surrounding the care of baby Charlie Gard, it has to be acknowledged that these are complex.

It would be easy enough to adopt the position that it should always be the parents choice to decide on the best treatment for their child, but this cannot always trump the legitimate concerns and responsibilities of doctors and nursing staff. It would of course be ideal if all choices on treatment, or of withdrawal of treatment and life support, could be made with agreement of both parents and doctors. But this cannot always be the case.

In the most difficult cases where there is disagreement about life support it will inevitably be decided by judges and through the legal process.

When the case was first heard I was asked as a medical ethicist to make a comment to the media. I chose not to do so because I could not know the full details of the case. This is true for most of us, and for many of those who chose freely to comment on it.

I can only comment in general terms, and not about a specific case. The facts need to be considered with compassion and understanding for all those involved - the medical staff and the parents, and of course baby Charlie.

We cannot expect doctors and nurses simply to provide treatment regardless of the overwhelming balance of probability that the treatment will cause more harm than it would relieve suffering. What we do understand about this particular case is that the treatment available in the USA has only a small chance of success.  Yes, that chance should be considered.

We might consider that any chance should be taken, but this would ignore the potential for needless suffering.

It is often said that the first rule in medicine is to do no harm. This is of course overly simplistic. It is often the case that treatment has both the potential for harm as well as for benefit. It is then a question of the balance of that benefit to harm.

These can be difficult to assess,  and the more so when dealing with the care of a baby. It is certainly the case that the progress in neonatal care and the improved outcomes would not have occurred if doctors had not pushed boundaries.

Whatever the 'rights' and 'wrongs' in the case of baby Charlie Gard, the staff at Great Ormond Street Hospital have legitimate concerns and are acting ethically in respect of their duties and responsibilities. They do not deserve to be threatened and abused.

Meanwhile our thoughts must be with the parents and with their baby. The parents, Connie Yates and Chris Gard are acting with great dignity and love for their child. They did not condone abuse and have also faced "nasty and hurtful remarks". They deserve to be heard and respected. So also do the doctors and nurses. Abuse of parents or doctors does not serve the interests of this baby, and it is unclear what the motives are of those behind the abuse.




Over 200 general practices closed or merged in England last year

As the population increases we would expect a concomitant rise in demand for health and social services. Good government would seek to meet that rising need, yet NHS funding has been essentially frozen over the last six years as part of austerity. This is despite the Tory claim in 2010 that they would 'ring fence' funding for the NHS.


The latest data from NHS Digital reveal there were 58,492,541 patients registered at GP practices in England on 1 July 2017. There were 2,427,526 more registered patients on 1 July 2017 compared to (56,065,015 ) 1 July 2013. Yet, there has been an insufficient increase in funding for the NHS to cope with this increased demand.


But the government not only denies cuts in funding, it says funding for the NHS has increased. It is a disingenuous defence. Of course funding for the NHS has risen, and funding is continuing to grow but at historically low rates and it is insufficient for services to meet increasing needs, and the rate of growth is slowing.

The Department of Health budget will have grown by just 1.1 per cent in real terms between 2009/10 and 2020/21. This is far below the long-term average increases in health spending of approximately 4 per cent a year in real terms since the NHS was established.


The problem is made worse in primary care because GP practices are closing or merging - 200 have closed or merged in the last year.

Furthermore, the BMA (British Medical Association) which represents doctors in the UK has warned that these figures are just “the tip of the iceberg”. Many more practices are at risk of closure because of rising demand, workforce shortages, and financial pressure.


The Department of Health budget is set to increase by just 0.6 per cent on average each of the next three years. As a result there will be increasing pressure on the NHS as demand for services is continues to grow.







Friday, 21 July 2017

Government 'in the dark' on migration

Brexit, we were told, was about 'taking back control'.  What that meant specifically was taking back control of our borders and immigration.  This was probably the biggest issue swaying voters in the referendum.  It masked all other arguments. 

Now a parliamentary committee warns that the government has no clear data on migration and the government is working 'in the dark'. 

The Government will struggle to take control of immigration post-Brexit unless major improvements are made to the quality of migration data upon which it currently relies, the Economic Affairs Committee says  in its report into Brexit and the Labour Market.

Commenting on the report, Lord Forsyth of Drumlean, Economic Affairs Committee Chairman, said:

"The Government must have reliable statistics on migration before it formulates new policy, otherwise it will be making crucial decisions - of vital importance to the country's businesses - in the dark.

"It will take companies time to adapt their business models to be less dependent on EU workers and an implementation period is essential to ensure a smooth transition.

"Businesses will have to accept that immigration from the European Union is going to reduce and adapt accordingly. Some firms will need to raise wages to attract domestic workers. In other sectors, where migrant workers may not easily be replaced by domestic workers, firms will need to change their business models or increase capital investment in automated processes. All these options may lead to higher prices for consumers.

"The Committee's 2008 report on immigration warned that the employment of migrant workers could lead to businesses neglecting skills and training for British workers. As the recruitment and retention problem in the nursing sector highlights, these fears have been realised and training for the domestic workforce needs urgently to be given a higher priority."

The report heard concerns about the impact of Brexit on the Labour market from many sources including the business community.

Many businesses told the committee they rely on migrant workers and there is uncertainty over the extent to which any post-Brexit immigration policy would take account of this.  Unless the transition arrangements are clarified soon, businesses also  are having to make contingency plans in the dark. 

Too much darkness, you might say.  Indeed,  and what business desperately needs is certainty in the labour market.  

We are now informed that the government will seek transitional arrangements to protect the economy, but there is little clarity about what these arrangements would be.   Businesses are having to take stock now,  and not wait for Brexit in 2019.   Furthermore, it will be more difficult for them to recruit skilled staff from the EU during the transition if job security becomes an issue.   Why would a skilled worker from the EU take the step of uprooting to live and work in the UK if they might not be able to employed there after 2 years?  

But why should British voters have any faith that leaving the EU would 'take back control of migration when the government hasn't successfuly limited the flow of non-EU migrants? In the year ending December 2016, it is estimated that 588,000 people migrated to the UK. Of these 250,000 were EU nationals, 264,000 non-EU nationals, and 74,000 British nationals.

The answer is complex, but then the factors driving migration are not simple.  They are a complex of economic opportunity, conflict, environmental change, and also the needs of the British economy.  

The term 'migrant worker' conjures images of low-skilled workers,  but the British economy relies on migration for the high-skilled Labour it needs.   The British economy has major skill shortages. 

In the end, if economic sense prevails, then the needs of the economy will trump any idea of 'taking back control'.   This is why Brexit Secretary  David Davis won't and can't give assurances that migration will fall after the UK leaves the EU.  

On what was a key issue for many voters in the referendum, those who voted for Brexit are in for disappointment, and it really brings into question the reasons we are leaving. 








Saturday, 8 July 2017

Rationing is fragmenting the NHS.

With rationing in the National Health Service there is a post-code lottery in treatment. An investigation by the British Medical Journal shows treatments available just a few months ago are no longer provided in some areas. This post-code lottery in available treatments is a shocking state of affairs, and is further evidence of a fragmenting health service.

There is no doubt the NHS is now struggling to cope with increased demand with limited resources. Commissioners and providers have had to face difficult decisions about how to prioritise limited funding and to balance their budgets.

Funding requests are a key marker of treatment rationing. An individual funding request can be made by clinician if they believe that a particular treatment or service that is not routinely offered by the NHS is the best treatment for their patient. As treatments become rationed or unavailable there is a concomitant increase in the number of funding requests.

Normally, the vast majority of treatments and services that patients need are offered routinely by the NHS, but the BMJ investigation shows that the overall number of individual funding requests received by clinical commissioning groups in England increased by 47% in the past four years. Thousands of patients are being turned down for funding each year, while many others are forced to wait for their treatment while their request is considered.

Whatever the government may say about NHS funding, what is clear is that funding per patient has fallen.

NHS Clinical Commissioners recently warned that Commissioning Groups would have £5.72 less to spend per person in 2019-20 than in 2016-17 under current funding from the government.

Clinicians are having to plead for funding for treatment for their patients. There has been a surge in funding requests for hip and knee surgery, cataract removal, and carpal tunnel surgery over the past four years and the consistently high number of mental healthcare requests.

Doctors have warned that rationing is leaving some patients in pain as they wait for treatment.







Wednesday, 5 July 2017

Soil carbon release accelerating global warming.

Could the release of carbon from the soil be  accelerating global warming and climate change?  The answer from the latest research published in Nature appears to be a resounding 'yes'.  This is perhaps not surprising given that the soil acts as a major store of global carbon.  It isn't simply locked in place. Organic processes release it to the atmosphere. 

Carbon is a vital ingredient of our living planet and plays a major role in the balance of our ecosystem.

All life on earth is 'made' of carbon and, simply put, carbon circulates. Carbon enters the atmosphere as carbon dioxide from respiration and combustion. It is absorbed by plants to make carbohydrates in photosynthesis using energy from the sun.

Animals feed on the plants passing the carbon compounds along the food chain. Most of the carbon they consume is exhaled back into the atmosphere as carbon dioxide. The animals and plants eventually die and these dead organisms are eaten by decomposers (microbes and animals in the soil), and carbon is returned to the atmosphere as carbon dioxide.

The  bulk of the planet's terrestrial carbon is retained in the soil. In this sense the soil acts as a carbon buffer or 'store', and it is this way that the exchange of carbon between the soil and atmosphere represent a restraint on atmospheric carbon dioxide and on global warming. 

This carbon cycle is driven by organisms (plants, microbes and animals) living in the soil, and these organic processes are enhanced when temperature rises.  Thus, a key question is whether anthropogenic (man-made) global warming in turn acts to increase the amount of carbon released from the soil.  

A recent study shows not only that this is the case,  but also suggests that this release of carbon from  the soil is now having a significant impact on global warming.

In a major international collaboration, scientists from universities and climate centres across the world have analysed soil samples from across the globe, from the arctic permafrosts to the dry Mediterranean forests.   They found the effects of temperature on soil carbon were variable but predictable.  The amount of carbon 'stored' in the soil varied inversely with temperature.

The findings of this study provide support for the contention that the release of carbon from the soil is having a significant effect on atmospheric carbon.  As global temperatures rise more carbon will be released into the atmosphere accelerating global warming.

As the authors of the study warn, reducing greenhouse gas emissions is vital if we want to avoid the most damaging effects of this carbon feedback over the course of the century.

Friday, 30 June 2017

Record Breaking Heat Wave Due to Man-Made Climate Change

Phew! June was a scorcher. The month of June 2017 was marked by high temperatures across Western Europe with heat waves triggering national heat-health plans and wildfires requiring evacuation in Portugal and Spain.

Record breaking heat gripped most of western Europe with mean temperatures 3 degrees above ‘normal’. England experienced the hottest June day since 1975. Belgium imposed water rationing because of record temperatures. In Switzerland a heat wave warning was issued, and in France and the Netherlands heat action plans were triggered.

France experienced the hottest June night ever recorded as the average nighttime temperature reached ​26.4 degrees Celsius on June 21st. Switzerland saw the second hottest day on record since records began in 1864. In England temperatures recorded at Heathrow reached 34.4 degrees Celsuis.

These high temperatures are no longer rare in the current climate, occurring roughly every 10 to 30 years.

So, was this heat wave a result of man-made global warming?

A detailed European collaborative study suggests it was, and warns that by the end of the century, these high temperatures will become the norm in Western Europe.

Scientists with World Weather Attribution (WWA) and partners in England, France and Switzerland conducted a multi-method analysis to assess whether and to what extent human-caused climate change played a role in the heat. The team found that climate change increased the frequency and intensity of such extreme events, which have at the very least doubled and in the south have increased by at least a factor 10.

First the team analysed the observed June temperature record in several Western European countries to assess whether or not there is a trend toward increasing temperature.

The next step was to assess whether and to what extent external drivers, in particular anthropogenic climate change, caused the positive June temperature trend in the observational data. To Answer this question they used climate models, in which the relative impact of various external “forcings” such as changes in solar insolation, volcanoes, and greenhouse gas concentrations can be quantified.

These model results indicate that past historical increases in greenhouse gases have raised the odds of a warm June in Belgium, France, the Netherlands, Portugal, Spain, Switzerland and the CET region of UK considerably. Furthermore, the observed trend is compatible with the effects of human-induced emissions of greenhouse gases.

Since past and projected future greenhouse gas increases will continue to increase the temperatures, the frequency of summer months like June 2017 should be expected to increase over the coming decades, and what is still an unusually hot June today would be a normal June later this century.




Sunday, 25 June 2017

Cry of the wolf - Apes, wolves, culture and intentions

Melvin Burgess' children story, Cry of the wolf, tells the tale of a man whose quest is to kill the last wolf alive in England.  One female survives, wounded by The Hunter, but she survives long enough to teach her sole surviving cub a few skills before she then is killed by the man. The cub is raised by a human family, but being a social animal he waits in vain for the scent of another wolf. 

When I consider how badly we treat other intelligent beings here on earth I am rather pleased that Extraterrestrial Intelligence continues to  elude us.  It would be better if we were at peace with ourselves, and that we care for our living planet before we blunder about in the nether reaches of the universe.

Tragically, when we have found other intelligent life here on our planet, we have tended to do it harm rather than give it respect.  Nonetheless we have a notion and a sense of fairness and justice, else we would not agonise over the problems this presents.  We have an increasing understanding about our planet and that we should protect it from the harm our activity may be doing.  Our intelligence, and our capacity to make reasoned choices enables us to do this.  Hopefully it will enable us to repair the damage we have done.

We are not alone in having a sense of fairness and justice. It is present in other cooperative mammals.  The results of a recent study suggest that Wolves also have a sense of fairness, or at least of inequity.

Wolves hunt, raise pups, and defend their territory cooperatively.  Equity is important in maintaining cooperative behaviour in the group.  Iniquitous treatment leads to aversive behaviour with withdrawal of cooperation.  This sense of fairness has long been seen in studies of non-human primates.  The psycho-social environment of members of a group in non-human primates has cultural complexity that profoundly influences behavioural development.   Such cooperation doesn't involve an incident by incident 'what's in it for me' assessment.  It is socially developed and socially maintained.  Mutual cooperation maintains social cohesion, not self-interest.  
 
Our planet is teaming with intelligent life. Problem solving is ubiquitous on earth.  It would be easy enough to regard organisms as mere automata - or gene-driven machines.  But this, I think, is a woefully inadequate understanding of living things, and of so much of animal life.  We have a strange view of ourselves as the only intelligent beings.  But even for us,  the gene-centred view of our being prevails. So much so that many question our capacity to make purposeful decisions.  That seems odd given I am writing this with the purpose of refuting such a view.  

Some groups of Apes use stones to crack nuts.  This use of tools is learned and culturally transmitted to others.  They will make choices about what stones are best for cracking nuts.  They will sometimes share good stones with other members of their group, but they will also covet a good stone, or keep one safe.  Apes also use tools to extract water to drink.  This is also culturally learned behaviour.  They have social intelligence, and they are able to make social decisions.  The use of tools is indicative of purposeful behaviour: the stone is selected and modified to best crack nuts.  

Nothing excites debate more than the question of whether we can or do make truly altruistic decisions, or whether all our behaviour is gene-directed self interest.  Altruistic behaviour is dismissed, where demonstrated, as being merely reciprocal. It is said to be self-interested action that preserves 'our' genes in the 'gene pool'.   It is odd then that I should write this to persuade you otherwise.  My genes did not write this. I did.  Your genes are not reading it. You are. 

The contention of behaviour driven by 'selfish genes' has left a powerful imprint on our politics and our economics. It underpins the neoliberal view of society as an aggregate of individual self-interested behaviour.  The operation of markets has been built on this notion.  It is used also to justify the iniquitous exploitation of others by a few. It has transformed the very nature of 'freedom' into a freedom to exploit. It is a strange notion of 'freedom' that is predicated on biogenic determinism.

Yet there is another view.  Our actions are not driven by genes.   We can, and we do, act with reason. Just as the apes select and modify good stones to crack nuts, so we also produce elaborate and technically complex tools.  We use these tools with purpose. Furthermore, we make assumptions about the reason of others. When I see Jack and Jill go up the hill and then come down again carrying a pail of water, I make an assumption that they went up in order to fetch the pail of water.  I might be wrong, or I may be right in my assumption.  That isn't really the issue here. What is at issue is that it is a reasonable assumption.  It follows reasonable logic.  Nor was Jack and Jill's behaviour caused by their genes, any more than it was caused by the feet with which they walked up the hill, or their hands with which they carried the pail, although in describing how they did what they did involved all of these.  

We might also hold this assumption about Jack and Jill's purpose with greater certainty if we knew that Jack and Jill needed or wanted water. That would certainly provide a motive or driver for the action. We might also know that the source of water was up the hill. 

My statement about 'why' Jack and Jill went up the hill makes a lot of interesting assumptions about behaviour, not least of which is that it is purposeful. It assumes that actions are or can be intentional. 

You might think it odd that anyone would doubt this. But they do, and I suppose the problem is best summed up in another question: where does this intention come from?  

In answering this we often end up with a distinctly unsatisfactory dualism - body and mind - as if the two were somehow of different  stuff, or no stuff at all.  Descartes had this problem.  If we are machines, robotic beings, then how could we have minds with intentions, thoughts and actions? He made a curious exception for humans - that we are machines with souls. This became a major distinction between humans and other animals.  It was all very unsatisfactory.

The modern gene-centred view has substituted another dualism - a bit of the machinery within the machine that drives the machine.  In this case genes.  This leads to the same problem.  If bits of the machine drive other bits, then how can there be free will?  And if there is no 'free will' then how can any behaviour truly be said to be intentional? 

The answer I think lies in logic.  Organisms are logically functional problem solving entities. They are open processes engaged with their environment, not closed systems like machines. 

Intention isn't a stuff. It is disposition. Thought isn't a stuff.  It is a continuous process.

So what then of our quest to find alien intelligence?

If we were to find extraterrestrial life then I think we would judge it intelligent not only by how well it solved problems but also by whether it had intentions.  Only by intention can we understand the cry of the wolf.

An extended version of this article can be heard on The Thin End podcast.


Acknowledgements.

My thanks to Denis Noble and Eva Jablonka for wonderful discussions that led to this post and accompanying podcast.










Friday, 23 June 2017

Imagine Brexit doesn't mean Brexit

Brexit, Brexit, Brexit. Do you remember when it all appeared so simple? Just a few weeks ago Mrs May was still delivering the mantra 'Brexit means Brexit'. That was before the general election. Now it doesn't appear so simple, and Brexit gets softer, and softer and....why?

Reality awakens. The truth is understood. Brexit isn't good. It isn't good for the economy, for jobs, for health and social care, for research, for fighting climate change, and so the negotiations now turn on how to ameliorate the harm it will do.

When these harmful effects were outlined in the EU referendum, they were dismissed as 'scare tactics' by the Leave campaign. But they are real. The government will try to negotiate some sort of access to the single market. It will do so because much of our economy depends on it. That access will come with a cost, and we will wonder what is better about it. "What's it all about Alfie? The question will be repeatedly asked. Why leave?

Ah, I hear it said 'to take back control!: But will we really be taking back control when we will have access to the single market on worse terms than we have now? Is that really sensible?

Of course, 'take back control' referred in large part to migration. We will take back control of our borders. Yet, what is this control? Is it really worth a can of beans?

Our health service is struggling with a staff shortage. It would be made much worse by our leaving the EU without making arrangements to recruit staff from the EU.

Mrs May is right, now and belatedly, to wake up to the problem. Up until the loss of her parliamentary majority she failed to give priority to the status of EU citizens working in the UK. It was a bargaining chip we were told. Now, a more sensible if not complete approach is being adopted. Let's hope it leads speedily to removing the uncertainty hanging over EU citizens resident in the UK.

I have been giving some thought on slogans Mrs May might adopt to regain her authority. She would have liked 'tough on Brexit, touch on the causes of Brexit'. But now  "Soft on Brexit, soft on the causes of Brexit' comes to mind.

When the impact of Brexit was put forward as a reason not to leave, we were told it was just an opinion. All at once 'experts' were dismissed as mischievous and plain 'wrong'. They didn't know what they were talking about, we were told. Their view was no better than...than anyone else.

And so it was that estimates of a loss of GDP of nearly ten percent modelled by the Treasury, NIESR and the Centre for Economic Performance at the LSE were dismissed in favour of populist Brexiteers.  Hardened Brexiteers pointed to disagreement in economic forecasts as a reason for ignoring them.  It was a bit like ignoring all weather forecasts on the basis that the don't always get it right - it might rain, but then again it might not.   Uncertainty of forecasting is no excuse for ignoring it. 

Similarly, warnings from the IMF and the OECD of the negative impact on the British economy were dismissed. "Well they would say that wouldn't they?"  Would they? 

So Her Majesty's Treasury forecast was a negative impact of between at worse -7.5 and at best  -3.8.  Rubbish the Brexiteers cried.  The Centre for Economic Performance forecast negative impact of -9.5 to -6.3. Rubbish the Brexiteers cried.  The National Institute for Economic and Social Research had negative impact of -9.2 to -2.4. Rubbish cried the Brexiteers.  

It became a mantra to dismiss such forecasts.  Brexit would be good for the economy.  The trick was then to make it almost unpatriotic to suggest Britain would struggle and 'could not stand on our own feet'.  Don't talk the country down.  "Be proud to be British!: "Britain" we were told "is strong".  We are up for it.  It was macho bravado! Things can only get better!  Ah, wouldn't it just.  

Certainly the realities of Brexit are  nuanced. But that alone will not be sufficient to mitigate the damage.  The simplistic 'the people have voted' approach is I suspect turning to a more realistic assessment of whether or what they voted for.  Brexit doesn't simply mean Brexit.   To say people voted to leave and to ignore the consequences is frankly abrogating any kind of responsibility.  It is a kind of 'now look what you made me do!"   It is time politicians were honest about it.  It is time they stopped simplistic slogans and owned up to the consequences.  This they are now having to do now Mrs May has lost her majority. 

Some of our EU partners are now saying they wish we would stay.   I wish we would too. 

European Council President Donald Tusk has quoted lyrics from John Lennon's Imagine to suggest the door remains open to the UK staying in the EU:  "You may say I'm a dreamer, but I'm not the only one."

You can listen to an extended version of this piece on The Thin End podcast.



Thursday, 22 June 2017

Impact on Health and Social Care should be centre-stage in Brexit negotiations.


With Brexit negotiations now underway this week the potential adverse impact on health and social care needs to be considered. The  British Medical Association, the voice of doctors in the UK, is calling on the government to protect future patient care by putting healthcare "front and centre" of its plans.

There can be little doubt that unless staffing issues are resolved the potential harm of Brexit to  health and social care is considerable.  The government should act speedily to resolve the uncertainty. 

Many health and social care professionals currently working in the UK have come from other EU countries, including 55,000 of the NHS’s 1.3 million workforce and 80,000 of the 1.3 million workers in the adult social care sector.   The NHS is currently struggling to recruit and retain staff.  Unless the future of NHS  and social care staff can be settled, then this problem is set to get worse with a deepening NHS and social care crisis.  

Since the vote to leave the EU, the BMA has been calling on the government to:
  • Give the 10,000 highly skilled EU doctors and medical researchers in the UK  permanent residence in the UK.  42 per cent of whom have told the BMA that are considering leaving in light of Brexit.
  • Ensure a flexible immigration system which meets the needs of the UK health service and medical research sector.
  • Preserve existing reciprocal arrangements, including mutual recognition of professional qualifications and measures which protect patient safety.
  • Secure ongoing access to EU research programmes and research funding, to maintain the UK's world-leading science and research base. 
  • Ensure Brexit does not hinder the UK's ability to play a leading role in European and international efforts to tackle global health threats.

Commenting ahead of the start of negotiations, Dr Mark Porter, BMA council chair said last week:

“With the NHS at breaking point, the government must keep the health service and its patients at the forefront during Brexit negotiations and control the impact that leaving the EU will have on health and social care across the UK."
The BMA warn that leaving the EU poses several risks to healthcare across the UK, not least in its staffing as almost half of the 10,000 doctors working here are considering leaving in light of the referendum result.

"These doctors have enhanced the UK’s medical research, brought expertise to the NHS and higher education, and filled shortages in specialties which may otherwise have been unable to cope. While we welcome the government’s pledge to provide certainty for EU nationals working in the NHS, the time has come for it to deliver fully on those repeated promises by providing them with permanent residence in the UK.

The BMA also call on the government to ensure long-term stability for the NHS by protecting life-changing medical research which benefits from European funding; ensuring that leaving the EU will not delay the UK’s access to vital pharmaceuticals, guaranteeing that leaving the EU will not hinder our efforts to tackle global health threats, and maintaining a soft border between Northern Ireland the Republic of Ireland to help ensure that cross-border health services and patient access to healthcare are not affected by leaving the EU.

The government must not use these workers as bargaining chips in the Brexit negotiations.  Guarantees should now be given that such workers can stay in the UK.

Update added 23rd June 2017 following Prime Minister's proposals on the rights of EU citizens living in the UK

Responding to the Prime Minister's proposals on the rights of EU citizens living in the UK following Brexit, Dr Mark Porter, BMA council chair has said:

“While we recognise these proposals are a starting position, they leave many unanswered questions, and only the full detail will show the potential impact they could have on medical research, and the NHS and its workforce.

“There are around 150,000 EU nationals working in the NHS and adult social care system in England. Already we know that more than four in ten doctors from the EU are considering leaving the UK in light of the referendum, with a further one in five unsure. 

“To provide stability to the NHS in the longer term, all EU doctors and academic staff currently in the UK should be granted permanent residence, regardless of how long they have been here.”