The healthmatters blog; commentary, observation and review
Two features in the latest edition (12th September 2015) of the British Medical Journal highlight the need for a Nanny State to promote and secure the public health
Firstly, a news item about a preliminary opinion of the European Court of Justice and secondly a Blog by Tim Ballard, vice chair of the Royal College of General Practitioners
The news item relates to the legislation passed by the Scottish government in 2012 to introduce a minimum price of 50p per unit of alcohol with the aim of reducing the prevalence of alcohol abuse. Implementation of the legislation was delayed because of a legal challenge from the drinks industry. The advocate general of the European Court of Justice has now concluded that national rules on pricing can be imposed that restrict trade and distort competition but only if they are appropriate for the attainment of the objective pursued and superior to alternative measures such as increased taxation.
Supporters of minimum pricing have welcomed this opinion as showing that minimum unit pricing is not precluded by EU law and can be implemented if it is shown to be the most effective public health measure available.
The Blog item is about Jamie Oliver’s new campaign for levying a voluntary sugary drink tax in restaurants as a means of tackling the obesity epidemic. It contains this statement by Tim Ballard, “Throughout my career I’ve been concerned by the desire of successive governments to place doctors in the front line to deal with the consequences of lifestyle choices, long believing that the pen in the hand of the legislator is mightier than the pen and the prescription pad.”
When I was a member of the now defunct Public Health Alliance/UK Public Health Association I was intrigued that one of its stated aims was to combat so called anti-health forces. Anti-health forces was a new term to me and at first it seemed rather fanciful, but now I understand that promoting the public health is a constant battle against the likes of the drinks industry in respect of alcohol abuse; and against the agri-food complex in respect of the obesity epidemic.
We need much more of the “pen in the hand of the legislator” and less of the pointless transfer of responsibility for tackling key public health challenges to doctors and others whose powers to make any impact are, as Tim Ballard acknowledges, very limited indeed. So, roll on the Nanny State – after all Nannies are good things!
Association equally significant among men and women, pooled data analysis shows
Eating a lot of fish may help curb the risk of depression—at least in Europe—suggests a pooled analysis of the available evidence, published online in the Journal of Epidemiology & Community Health.
The association between a fishy diet and mental health appears to be equally significant among men and women, the first analysis of its kind indicates.
Depression affects an estimated 350 million people worldwide, and is projected to become the second leading cause of ill health by 2020.
Several previous studies have looked at the possible role of dietary factors in modifying depression risk, but the findings have been inconsistent and inconclusive.
The researchers therefore pooled the data from relevant studies published between 2001 and 2014 to assess the strength of the evidence on the link between fish consumption and depression risk
After trawling research databases, they found 101 suitable articles, of which 16 were eligible for inclusion in the analysis. These 16 articles included 26 studies, involving 150, 278 participants.
Ten of the studies were cohort studies, which involve monitoring a group of people who don’t have the condition in question for a period of time to see who develops it. The remainder were cross-sectional: these look at the association between a condition and other variables of interest in a defined population at a single point in time or over a brief period.
Ten of the studies involved participants from Europe; 7 those from North America; the rest involved participants in Asia, Oceania, and South America.
After pooling all the data together, a significant association emerged between those eating the most fish and a 17% reduction in depression risk compared with those eating the least. This was found in both cohort and cross-sectional studies, but only for the European studies.
When the researchers looked specifically at gender, they found a slightly stronger association between high fish consumption and lowered depression risk in men (20%). Among women, the associated reduction in risk was 16%.
This is an observational study so no definitive conclusions can be drawn about cause and effect, added to which fish consumption was measured using different dietary assessment methods across the various studies. But there may be a plausible biological explanation for the link, suggest the researchers.
For example, it has been suggested that the omega 3 fatty acids found in fish may alter the microstructure of brain membranes and modify the activity of the neurotransmitters, dopamine and serotonin, both of which are thought to be involved in depression.
Furthermore, the high quality protein, vitamins, and minerals found in fish may help stave off depression, while eating a lot of fish may be an indicator of a healthy and more nutritious diet, suggest the researchers.
“Higher fish consumption may be beneficial in the primary prevention of depression,” they conclude, adding: “Future studies are needed to further investigate whether this association varies according to the type of fish.”
Around 1000 nurses from outside of the European Union have been rejected to date by the Home Office with a further 1000 nurses expected to apply to work in the UK in the next 6 months. NHS Employers warns that immigration rules are compromising patient safety, cost controls and leaving a shortage of nurses and doctors at a crucial time.
If NHS Trusts are not able to recruit overseas nurses there is a risk that clinical services will be compromised especially in the coming winter months when demand for care is highest. This could lead to delays for patients, their families and risks operations being cancelled and treatments being delayed. Figures from NHS England show there is increasing demand on the NHS to meet patient need at a time when there is a nursing shortage in the UK. Trusts need to recruit large numbers of nurses from outside of the EU to provide a sustainable workforce in the NHS.
While plans are in place to train more nurses in the UK, it takes four years to commission and deliver the training so we will not see the benefit until 2017 at the earliest. In the meantime, the NHS’ priority must be to ensure that there is sufficient staffing to deliver good patient care in hospitals across the country. The NHS values migrant doctors and nurses who have contributed a significant amount to the way we deliver care to our patients.
NHS Employers has written to the Home Secretary Theresa May to raise these concerns and is keen to be helpful to the Home Office’s policy implementation in these and related issues. The letter is signed and supported by many trusts across England and co-signatories include Sir Robert Naylor (UCLH), Sir Len Fenwick (Newcastle) and Sir Andrew Cash (Sheffield).
Danny Mortimer, Chief Executive of NHS Employers, said:
“Hospitals strive constantly to deliver the same high standard of care to patients amid rising demands. Even with Government commitment to additional training places for nurses and a focus on retention, we need to employ staff from outside the EU to meet current demand for staff. Due to the high demand for immigration certificates in June and July, for example, all of the applications for nurses were rejected. Whilst there was some improvement in August, with 200 certificates being issued there remains significant numbers of outstanding applications for entry to the UK to take up nursing posts in our hospitals. If Trusts are unable to employ these nurses it will impact on their ability to meet safe staffing levels and support the effective provision of services particularly in the winter months.
“Non-EU nurses are invaluable to the NHS. Whilst we are experiencing a mismatch between supply and demand we are asking that this is recognised and that nursing be placed on the shortage occupation list for the next two years.”
The National Audit Office has published the findings from its investigation into managing conflicts of interest in NHS clinical commissioning groups. All GP practices are members of their local CCG. Within each CCG, some GPs are members of their CCG’s board – its governing body. Under these arrangements there is potential for some GPs and their colleagues to make commissioning decisions about services they provide, or in which they have an interest. Where this is the case there is a risk that commissioners may put, or be perceived to put, personal interests ahead of patients’ interests.
The key findings of the investigation are as follows.
· Some 1,300 (41%) of CCG governing body members in position at the time of our analysis in 2014-15 were also GPs, who may, potentially, have made decisions about local health services and have been paid by their CCG for providing them
· The Department recognised the potential for conflicts of interest in the NHS commissioning system and took a proportionate response to managing such conflicts, including by assigning formal roles to relevant bodies
· The Health and Social Care Act 2012 places a legal duty on CCGs to manage conflicts of interest. The NAO found almost all CCGs had put in place most key elements of the legislative requirements which help them to prevent and manage conflicts
· During 2014-15, a minority of CCGs had reported they had to manage actual or perceived conflicts of interest. However, the NAO could not always assess from publicly available information how CCGs had managed such conflicts of interest, which limits local transparency
· Where CCGs reported information about their controls for managing risks of conflicts of interest, it showed the adequacy of those controls had varied
· NHS England has so far collected little data on how effectively CCGs are managing conflicts of interest or whether they are complying with requirements. It relies instead on an exception-based approach, and on Monitor as the system regulator
· Up to June 2015, Monitor had received relatively few concerns about conflicts of interest; only one of its formal investigations included a concern about conflicts of interest in a CCG
· From April 2015, CCGs can choose to co-commission primary care services from GPs which is likely to increase significantly the number and scale of conflicts of interest. The Department and NHS England recognise the risk and have responded, including issuing statutory guidance and providing training and support to CCGs.
To promote public confidence that conflicts are well managed, CCGs will need to ensure transparency at the local level when making commissioning decisions. In addition, NHS England will need to be satisfied that it has sufficient and timely information to assure itself that CCGs are managing conflicts promptly and effectively.
To mark World Suicide Prevention Day (10 September 2015), Samaritans is encouraging anyone worried about a friend, colleague or family member who may be struggling to cope to ask, ‘Are you OK?’.
In the UK and the Republic of Ireland, more than 6,000 people die by suicide each year – an average of 18 people every single day. Every 6 seconds Samaritans responds to a call for help, by phone, email, text or face to face in its 201 branches.
Not everyone finds it easy to start a conversation that may be uncomfortable, and not everyone shows signs that they are struggling with difficult thoughts or feelings. But simple human contact -knowing that you’re not alone with your troubles and that someone will listen – can make a big difference, even at the most difficult of times.
In research carried out for Samaritans, only a quarter of people (29%) said they would be happy to encourage others to talk about their problems and when asked if they would approach someone who looked upset, three-quarters (75%) said they would not.*
Samaritans CEO, Ruth Sutherland, says we need to be braver as just a simple question, to encourage a person to talk about their problems, can help them to feel less isolated, and more able to find a way through.
“It’s not always obvious that someone is struggling to cope. It may be that they just can’t find the words, don’t want to burden others, or fear they will be judged. If you ask, ‘Are you OK?’ and show you are there to listen, people are far less likely to feel they have to go it alone with their troubles. It’s not t always about looking for someone to fix a problem – sometimes the biggest help can be having someone to share it with.
For anyone who doesn’t want to talk to someone they know, or who is worried about someone else, Samaritans is here round the clock, every single day of the year to listen in confidence about whatever’s troubling them.”
Professor Rory O’Connor from the University of Glasgow leads research into suicidal behaviour and has worked with Samaritans on understanding why some people are more at risk.
“If you bottle things up, you can feel trapped in your situation. Knowing you’re not alone, not the only one who’s felt this way, and that people will listen, is something to hold onto, even in the most difficult of times. A person focused on taking their life often finds it difficult to see alternatives. This intense period only lasts a short while for many people. So for some, even small things like knowing you are not alone can do a huge amount to bring them back from that decision.”
People looking for support to start a conversation with someone they’re worried about can find tips and guidance on Samaritans’ website at www.samaritans.org/wspd or follow Samaritans on Twitter @samaritans, #RUOK or find them on Facebook www.facebook.com/
BMA responds to BMJ analysis of weekend admissions – Patients should have access to same quality of care seven-days a week, says BMA
Responding to analysis published in the BMJ on weekend admissions which found that fewer but sicker patients are admitted at weekends, and calls for more research into how services can be improved, Dr Mark Porter, BMA council chair, said:
“Doctors want the care we provide for sick patients to be of the same high standard, seven days a week. Urgent action on this has been undermined by calls for the entire NHS to be delivered on a seven-day basis without any clear prioritisation.
“The BMA wants better access to seven-day urgent and emergency care to be the priority for investment1. This will ensure seriously ill patients receive the best care at all times. Nine in 10 consultants already work around the clock delivering this care2but additional services will require not just more doctors, but extra nurses, diagnostic and support staff.
“David Cameron promised a ‘truly seven-day NHS’3 but there has been no detail to define what he means, how he plans to fund and staff it, and its impact on weekday services. Given the current funding squeeze on NHS Trusts, the only way for many hospitals to increase the number of doctors over the weekend would be to reduce the number providing care during the week.
“If the government really want to deliver more seven-day services then they need to show patients, the public and NHS staff their plan for how this will be delivered at a time of enormous financial strain on the NHS and when existing services and staff are under extreme pressure.”
Switching from “one size fits all” to a personalised approach based on free open source kitchen design software could dramatically slash the annual cost of adapting the homes of elderly patients on their discharge from hospital.
Research from occupational therapy and computer science academics from Brunel University London shows that more than half of the costly equipment from shower chairs to grab rails installed in their homes for such patients is ever actually used.
The Brunel solution could also speed up the whole process of pre-discharge home visits by occupational therapists (OTs) relieving hospitals of “bed-blocking” elderly patients who are healthy enough to go home at a further cost to the NHS of more than £500 a night.
Explained Dr Arthur Money, who led the team: “Pre-discharge home visits are routinely carried out to make sure the transfer from hospital to home is safe for the patient.
“But there are issues not only with the speed of the process but the lack of shared decision making which leads to more than half of assistive equipment installed not having been used when OTs make follow-up visits.”
He added: “While some adaptations may fall into the not-needed-yet-but-will-be-
“And many patients find the home visit itself demoralising, daunting and anxiety provoking. Our software turns the home visit into a collaboration between patient and OT.”
OT lecturer Dr Anita Atwal says the software also helps bridge the information gap where elderly people are not quite sure what a piece of equipment is or does but are reluctant to show their ignorance to an expert.
“As OTs one of the most striking lessons from the research is when older people were placing items of what to us is part of our everyday work in the wrong places – quite clearly not understanding what the equipment was for.”
Fellow Brunel OT lecturer Lesley Wilson added: “It also became clear that while the hacked interior design software is a great tool for both patient and OT it needs to be used in a partnership approach.
“Older people using it hands-on in our study were very clear they saw it as a great tool but one to be used together with their OT. And many have already encountered versions on the High Street from estate agents to kitchen design outlets.”
The team plans further developments to the software in the next phase of the research including the ability to introduce the patient into their adapted virtual home by building accurate to real-life scale avatars.
Said Dr Money: “Just in the same way as different people want a different kitchen counter height items such as grab and hand rails need to be installed at a comfortable height for the patient. Introducing avatars will help OTs get that aspect right.”
The Mental Health Foundation (MHF) and the Foundation for People with Learning Disabilities (FPLD) comment on the inappropriate use of psychotropic drugs in people with a learning disability.
A study by a team of researchers at University College London (UCL), published in the British Medical Journal, has found that “the proportion of people with intellectual disability in the UK who have been treated with psychotropic drugs far exceeds the proportion with recorded mental illness”. This has led researchers to suggest “in some cases, these drugs are being used to manage other presentations, such as challenging behaviour, rather than for mental illness.”
The study analysed data from 571 UK general practices and identified 33,016 people with a record of intellectual disability “of the 11,915 with a record of challenging behaviour, 5,562 (47%) had received antipsychotic drugs, whereas only 1,561 (13%) had a record of severe mental illness”.
Commenting Jenny Edwards CEO of the MHF and the FPLD said:
“We are deeply concerned by the volume of people identified by this research with challenging behaviour prescribed psychotropic drugs despite not been diagnosed as having a serious mental health problem. It has long been recognised that psychotropic drugs and antipsychotics have been overused in people with learning disabilities. Both the Mental Health Foundation and the Foundation for People with Learning Disabilities join the widespread calls to review the prescribing of psychotropic drugs and to improve therapeutic interventions available for people with learning disabilities.”
Christine Burke, Senior Development Manager for the FPLD said:
“The Foundation for People with Learning Disabilities welcomes this research for giving us an improved evidence base to challenge bad practice. Our work is based on the prevention of inequalities, such as our Feeling Down report which called for improved recognition and diagnosis of mental illness and our work with mainstream mental health services to improve access.
“We support the call by the UCL research team for an improved evidence base for the use of psychotropic drugs and its impact on the overall health of people with learning disabilities. We also call for the urgent development of therapeutic strategies that would reduce the high use of psychotropic drugs.”
- Fewer patients are admitted at weekends, but are more likely to be sicker and have a higher risk of death from Fridaythrough until Monday
Authors caution against using the data to estimate avoidable deaths, but call for more research into how services can be improved to reduce risk
Patients admitted to hospital at the weekend are more likely to be sicker and have a higher risk of death, compared with those admitted during the week, finds an analysis published in The BMJ this week.
The analysis was carried out as a collaboration between University Hospital Birmingham NHS Foundation Trusts and University College London, and included Sir Bruce Keogh, National Medical Director of NHS England. It examined the effect of hospital admission day on death rates across NHS England hospitals for 2013-2014.
The results confirm findings from an analysis they undertook for 2009-2010.
In the latest analysis, the authors found that around 11,000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday, or Monday compared with other days of the week (Tuesday, Wednesday, Thursday).
This suggests a generalised “weekend effect” which can be partly explained by the reduced support services that start from late Friday through the weekend, leading to disruption on Monday morning, say the authors. Patients already in hospital over the weekend do not have an increased risk of death.
These results remained the same even when taking into account the severity of illness.
The authors caution that it is not possible to show that this excess number of deaths could have been prevented, adding that to do so would be “rash and misleading.”
Nevertheless, they say the number is “not otherwise ignorable” and “we need to determine exactly which services need to be improved at the weekend to tackle the increased risk of mortality.”
They also looked at patient characteristics, length of hospital stay, and time to death.
An average of 2.7 million patients were admitted to hospital on each weekday, while an average of 1.2 million patients were admitted on a Saturday and 1 million patients admitted on a Sunday.
Saturday and Sunday admissions were more likely to be emergencies, 50% and 65% respectively, than on weekdays (29%) and length of stay was also higher for patients admitted on a Saturday and Sunday.
A higher proportion of patients admitted on a Saturday and Sunday had diagnoses that placed them in the highest risk of death category, 24.6% and 29.2% respectively, compared with less than 20% of weekday admissions.
The debate on seven day working was reignited following health secretary Jeremy Hunt’s recent call for hospital doctors to work at weekends to improve quality of care and reduce deaths.
But an accompanying feature article by Helen Crump at the Nuffield Trust says it is not clear how or to what extent investment in seven day services will reduce weekend deaths, and that the costs may outweigh any benefits.
She also warns that, unless overall staffing levels increase, ramping up services at the weekend “will leave a gap in the hospital’s weekday rota, with potentially serious consequences across other services.”
In a linked editorial, Paul Aylin, from Imperial College London, suggests more research is needed to determine the “complex” relation between staffing levels and services, and patient safety. He says promised changes to how the NHS provides weekend and out of hours care “will be an ideal opportunity to evaluate their impact on the weekend effect.”
Seven day working has also been a central part of negotiations between the government and doctors about proposed changes to the standard contract for NHS consultants. Hunt announced that the government would remove a clause in the contract which allowed doctors to opt out of non-emergency work at weekends. But figures obtained from freedom of information requests by BMJ Careers show that just 1% of consultants have opted out of non-emergency weekend work.
A new molecular test, which can indicate how well a person is ageing, could transform the way ageing is approached in medical research by assessing a person’s ‘biological age’ rather than the number of years they have lived.
The findings, published today in Genome Biology, could help improve management of age-related disease by identifying people most at risk of diseases affected by age, as well as improve the way anti-ageing treatments are evaluated.
The seven-year collaborative study at King’s College London, Karolinska Institutet in Sweden and Duke University in the USA, used a process called RNA-profiling to measure and compare gene expression in thousands of human tissue samples. Rather than looking for genes associated with disease or extreme longevity, the Medical Research Council (MRC)-funded researchers discovered that the ‘activation’ of 150 genes in the blood, brain and muscle tissue were a hallmark of good health at 65 years of age. The researchers were then able to create a reproducible formula for ‘healthy ageing’, and use this to tell how well a person is ageing when compared to others born the same year.
The researchers found an extensive range in ‘biological age’ scores of people born at the same time indicating that a person’s biological age is separate and distinct to his or her chronological age.
Importantly, a low score was found to correlate with cognitive decline, implying that the molecular test could translate into a simple blood test to predict those most at risk of Alzheimer’s disease or other dementias and suitable for taking part in prevention trials.
A person’s score was not, however, found to correlate with common lifestyle-associated conditions, such as heart disease and diabetes, and is therefore likely to represent a unique rate of ageing largely independent of a person’s lifestyle choices.
The researchers say their findings provide the first practical and accurate test for the rate at which individual bodies are ageing. If this is the case, it could lead to numerous insights in research because ‘age’ is a critical factor in almost every area of medicine.
At the same time, the molecular test could enable more suitable donor matching for older organ transplants and could also provide a more efficient way of determining if an animal model of ageing is suitable to evaluate the effectiveness of anti-ageing treatments.
However, the study does not provide insight into how to improve a person’s score and thus alter their ‘biological age’. While a low score could be considered as ‘accelerated ageing’, an important aspect of the work suggests that ageing does not now need to be defined only by the appearance of disease.
Lead author of the study, Professor James Timmons at the Division of Genetics and Molecular Medicine at King’s College London, said: “Given the biological complexity of the ageing process, until now there has been no reliable way to measure how well a person is ageing compared with their peers. Physical capacity such as strength or onset of disease is often used to assess ‘healthy ageing’ in the elderly but in contrast, we can now measure ageing before symptoms of decline or illness occur.
“We now need to find out more about why these vast differences in ageing occur, with the hope that the test could be used to reduce the risk of developing diseases associated with age.”
Dr Neha Issar-Brown, programme manager for population health sciences at the MRC added: “Whilst it is natural for our bodies and brains to slow down as we age, premature ageing and the more severe loss of physical and cognitive function can have devastating consequences for the individual and their families, as well as impact more widely upon society and the economy.
“This new test holds great potential as with further research, it may help improve the development and evaluation of treatments that prolong good health in older age.”
This research was funded by the Medical Research Council, the Innovative Medicines Initiative (EU/EFPIA), the Wallenberg Foundation and the National Institutes of Health.