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.