medicine interviews: NHS hot topics

State of the NHS: summary (ABCD)

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Sate of the NHS: A

Ambulances:

* work on response time at point of dialling for emergency services
* response time is organised into categories
* Category 1: immediate response to a life-threatening condition, such as cardiac/ respiratory arrest. avg response time 7 mins and 90% amb to arrive within 15 mins
* Category 2: serious conditions, such as strokes or chest pain, which require rapid assessment + urgent transport. response under 18 mins and 90% amb within 40 mins
* Category 3: urgent problems, uncomplicated diabetic issue that requires and acute setting. 90% within 2 hours
* Category 4: non-urgent problems, stable clinical cases that need a hospital ward/clinic 90% within 3 hours.
* performance currently mixed- 1.36 mins above 8 min target for C1
* highlighted cases included by BBC as Ldn amb taking 70mins to a C1 case and stroke patient dying after waiting 8 hours

causes of long ambulance wait times

* unprecedented levels of demand post-covid- 860k calls to 999 in apr 2022 +20%
* post-2010 cuts to community services resulted in greater pressures on emergency services - people entering the health system later with worse issues.
* shortage of paramedics- GMB union found 1000 workers left as a result of work-life balance
* A&E waiting times- ED overcrowding, slowing crews having to wait with patients

govt response to ambulance times

allocation of £150 mil to address waiting times and given 3% pay rise to incentivise

but 150 mil only 0.1% of NHS budget

State of the NHS: B

Backlog:

* causes longer ambulance response times
* suspension of elective treatments in covid caused waiting lists briefly fell
* sep 2020 caused a steep climb in the number of people on NHS waiting lists

Consultant led elective care:

* may 22, 7 million people on waiting lists for consultant led elective care, double 2015


* 2.75m are waiting more than 18 weeks for treatment
* 390,000 are waiting more than a year for treatment, 375x more than jul 2019
* BMA worry of ‘hidden backlog’, people who would have presented themselves but chose not to- or had referrals cancelled
* causes strain on amb waiting times as people are then presenting with more acute issues

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A&E waiting times

* Nuffield study shows that for less serious visits, 4hr target has been largely met
* Q3 showed 96% of C2 and 3 visitors seen within 4 hours
* only 60% for C1 patients referred or discharged within 4 hour target, delays ambulance response times
* people waiting more than 12 hours in ED increased by 14%

Cancer waiting times

* target time for cancer patient being referred from a GP to Consultant is 2 weeks. 90% should be seen in time and receiving treatment following GP referral
* pandemic allowed NHS to reach targets, but aug 2022, only 75% of patient referred by a GP had seen a consultant in time , 62% starting treatment in time
* attendance has only returned to pre-pan levels instead of exceeding

factors contributing to backlog

* pandemic


* severity of conditions admitted
* longer ambulance response time
* changes in community health provision

State of the NHS: C

Care:

* aids elderly, young families, mentally ill, addition and dependency
* supported by community before needing GPs, hospitals and emergency services
* positions opened increased by 0.3%, applications down 3%
* 165k posts vacant, 10.7% of available posts
* 4.5 m members of public have become unpaid carers for loved ones since the pandemic began = 13.6m people

causes of care staff shortage

* 2019-2021 pay rise did not align with national wage
* average hourly wage for care workers is £9.50 - other jobs are less demanding and pay more
* in jan 2021, it became impossible due to Brexit for someone in the EU to work in UK care sector

State of the NHS: D

Doctors and dentists:

* progress in raising number of med students and 50k more nurses by 2024/25, less progress in access to GPs and dentists
* King’s fund found that gov target of 6k more GPs is likely to be missed + 26k more healthcare workers
* 2022 analysis found shortage of 4.2k GPs, suggested to increase to 8.8k by 2030 = more admitted to A&E
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types of A&E departments

Type 1 :

major emergency consultant led providing 24 hour service - have most attendances

Type 2:

specific specialties - dental, eyes etc

Type 3:

minor injuries and illnesses, e.g. walk in centres/ minor injury

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why are patients waiting longer in A&E?

* rising attendances
* fewer hospital beds ( exit block delays diagnosis and treatment)
* age of patients 75% of 75 y/o have more than one long term condition, 82% in 85 year olds
* unnecessary A&E attendances - can’t get GP appointment
* Delayed discharges - need home support of nursing home
* staffing shortage- increased workload, exacerbated by burnout and the pandemic
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the four hour target- what does it measure and what other factors contribute to performance ?

* two departments could see the same proportion of patients within four hours with different average waiting times
* consider number of re-attendance within 7 days
* waiting time to see a clinician
* Care Quality Commission rating of core hospital services
* patient satisfaction
* suggested in march 2019 to get rid of 4hr standard but remained as of sep 2022

other solutions to A&E waiting times

* assemble GPs, A&E staff, pharmacists and urgent care teams to new emergency and urgent care hubs
* serve larger areas and reduces strain
* larger investment in primary care would help
* pilot in Peterborough and Cambridgeshire ran a pilot of local urgent care services at three hospitals - ‘one stop service’ for minor injuries and illness. 13.5k used in first year and reduced pressure on A&E

most common issues with GPs and primary care

* GP shortages
* increasing demand, 34k GPs need to keep up with pop growth and age
* recruitment issues- pledged to hire 5000 new GPs by 2020 but matt h said it would not be met
* 2019, 3538 GP training places were accepted, highest in history of NHS
* Practices are closing- 99 practices were closed
* 40% of GPs planning on leaving by 2023
* unsafe patient levels- 10% patients seeing 60+ patients a day double safe number
* long waits for appointments - 33% waited over a week for an appointment
* unnecessary appointments waste time
* public satisfaction is low

solutions for GP services and primary care

* medical schools are trying to correct misconceptions about GP and encouraging the role
* NHS has a 10m scheme to incentivise FYs to become GPs
* as of 2017, golden hello one off payment of 20k to new GPs in rural and coastal areas, doubling GPs in hard to recruit areas
* short term solution of International recruitment
* ‘primary care network’ of 20k more staff of pharmacists, physiotherapists and paramedics
* digital solutions- telephone triage, video consultations and e-consultations

what is organ donation ?

act of giving an organ to someone who is in need of a transplant

can come from living or dead

challenges with organ donation

* 7000 people on waiting list
* 2020/21 , 470 + patients died waiting for an organ
* only a small proportion of deaths leave viable organs due to circulatory requirements
* better vehicle manufacturing means that less deaths occur as a result of head injury that leaves viable organs
* organs also need to match
* only 39% of BAME family agreed to support donations going ahead compared to 69% white due to lack of discussion and religious beliefs

opt-in system

with this, organs can only be used if person signed up to organ donor register

* 80% supported organ donation but only 38% opted in so it didn't translate
* argued to be most ethical form of consent as it’s explicit

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opt-out system

deemed/presumed consent if person has neither opted in or out

adopted by England, Wales and Scotland to increase number of people on the register as only those with strong views will opt out

considered less ethical due to lack of awareness

organ donation in the UK

* Dec 2015 Wales moved to soft opt out- family has final say
* Wales has highest consent rate in all of the UK
* 2020 England adopted soft opt out- over 18 automatically added and have to actively withdraw to opt out + family still consulted
* NI has opt in, Scotland opt out since 2021

opt -in vs opt-out

* Spain has highest organ donation rate with soft opt in system whilst opt out Luxembourg and Bulgaria have very low rates
* Hard opt out +25% in donations but it is controversial for families
* Israel incentivises with opt-in with priority on donation register with opting in
* communication, education and awareness need to be raised in order to succeed

abortion definition

* medical process of ending a human pregnancy so that it doesn’t end in the birth of a baby
* legal in England, Wales and Scotland up to 24 weeks
* may only be legally carried out if two doctors agree that continuation will negatively impact physical / mental health / health of existing children
* legal after 24 wks if woman’s life is at risk, child is born with severe disability or a risk of grave physical. mental injury to the woman

surgical abortion

operation to remove pregnancy from the womb

medical abortion

within 10wks of gestation - take two pills 24 to 48 hours apart

1st taken at a clinic- mifepristone

2nd at home or clinic to pass the pregnancy

abortions at home

2018, gov allowed women allowed to take pill at home - prevents risk of miscarrying on their journey home

compassionate measure but argued by pro-life to trivialise abortion

in response to pandemic, in march 2020, women were allowed to take both pills at home

legal debates surrounding abortion

* when the foetus becomes a living organism
* at which point it is considered murder

NI and abortion rights

* until oct 2019, abortion was illegal in NI unless woman’s life was at risk or if the pregnancy would cause serious physical/ mental health effects to the women. Rape, incest and fatal foetal abnormalities were not grounds for abortion
* 2017, uk gov allowed NI women to access NHS funded abortions in the UK
* may 2018, Republic of Ireland voted overwhelmingly to overturn abortion ban
* NI voted in referendum to make abortion legal, with 66.4% voting to amend constitution
* oct 2019, abortion decriminalised and became lawful
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the abortion regulations 2020

31st march 2020- termination of pregnancy is allowed:

* unconditionally prior to 12 weeks
* up to 24 weeks when continuing a pregnancy would risk mental or physical injury to the woman or girl that is greater than the risk of terminating the pregnancy
* after 24 weeks when there is substantial impairment to the foetus, including when death is likely before, during or shortly after the birth
* must only be carried out by registered medial professionals but those using abortion pills bought online are no longer prosecuted and health professionals are no longer required to report the use

Ethics: Pro-Life

some believe that:

* human life begins at the point of conception and therefore abortion amounts to murder
* instead of carrying out abortion, the child is to be adopted if the parents cannot take care of them
* some may be pregnant as a result of rape or incest but the child is innocent and should not be punished as a result
* an abortion can cause psychological distress
* all children have great potential and a woman could abort a foetus is importance to the world
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Ethics: Pro-Choice

some believe that:

* almost all abortions are carried out in the first three months of the pregnancy, when the foetus cannot exist independently outside the mother’s womb and therefore cannot be regarded as living
* Fertilised eggs used in IVF and often thrown or destroyed if not implanted- but this is not considered murder
* in the case of rape or incest, forcing a woman to have the child is more psychologically damaging than having an abortion
* keeping abortion legal prevents deaths and complications from unsafe backstreet abortion
* abortion may be necessary to save the woman’s life in certain cases

euthanasia definition

* ending a patients life who is suffering from an incurable/ painful disease/ irreversible coma

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Active euthanasia

when the acting person deliberately intervenes to end someone’s life.

Passive euthanasia

when a person causes death by withholding or withdrawing treatment that is necessary to maintain life

voluntary euthanasia

when it is carried out at the request of the person who dies

involuntary euthanasia

murder

assisted suicide

the physician gives the patient the means to take the lethal medication themselves

assisted dying

used in the context of when a patient who is already dying and asks for help to die

laws around euthanasia and assisted suicide in the UK

both euthanasia and assisted suicide are illegal in the UK

* Euthanasia is punishable by life imprisonment
* assisted suicide is illegal under the 1961 suicide act and punishable by 14 yrs in prison
* passive euthanasia is illegal, but NHS states that withdrawing life-sustaining care when in patients best interest can form part of good palliative care

legal challenges to euthanasia 2015-2021

2015- House of Commons rejected bill 330/118 that allowed terminally ill patients in last six months to be prescribed medication to administer themselves, with mental health being verified by two doctors

2018- UK Supreme Court ruled legal permission no longer needed to withdraw treatment from patients in permanent vegetative state BMA and RCP published guidelines on this

may 2019- Paul Lamb, who lives with chronic pain following a crash renewed a bid for the right to die after denial from Supreme Court in 2014 previous bills for terminally ill patients were denied and Mr Lamb’s case differed in that he was expected to live a long time

September 2019- 80 year old Mavis Eccleston was cleared of murder and manslaughter after getting her husband medication to overdose. the cancer patient had his wishes respected, according to daughter- mavis overdosed also but recovered in hospital

nov 2019- 49 year old Paul Newby lost his high court case challenging assisted dying, proposing that evidence be thoroughly examined before deciding if AD was incompatible with human rights

aug 2020- relatives of people previously brought legal cases for assisted dying came together to make a joint enquiry

September 2021- members of the BMA voted to adopt neutral stance on assisted dying, 49% in favour, 48% opposed and 3% abstaining, previously opposed entirely.

Euthanasia in other countries

* Currently legal in Netherlands, Colombia, Luxembourg, Belgium, Canada, Spain, NZ and some parts of Aus
* in Aus, voluntary assisted dying scheme in western Australia was introduced, joining Victoria, which allowed voluntary assisted suicide, allowing doctors to prescribe and administer if necessary
* NZ, end of life choice bill passed by parliament in 2019, 65.1% of the vote in referendum, came into effect nov 2021

arguments in support of euthanasia

* compassionate end to suffering when palliative care is not enough
* upholds autonomy
* current UK law means patients have to travel abroad to die when they would rather die at home surrounded by loved ones
* public increasingly supports assisted dying - gov needs to represent democracy
* provides comfort in the option for dying
* does not cause harm to others and therefore the dying’s wish
* some may carry it out alone leading to prolonged suffering- therefore legalisation prevents deaths overall
* would reflect changing attitudes
* some docs argue it provides clearer legal framework for end of life care - some EOL care can cause double effect, where it is legal to give life- shortening treatment to alleviate pain
* Oregon’s ‘death with dignity act’ shows that opposition changed after no evidence being found that assisted dying has undermined organs eol care of undermined interests of the vulnerable

arguments against euthanasia

* many argue that it turns doctors into executioners, at odds with principle of non-maleficence
* many are concerned that it allows the law to change for more people- Belgium has a law that legalises euthanasia for children
* consent that it sends out a message that when life falls short of criteria, is justifies assisted dying
* does not help with those who are terminal and unable to take their own lives- e.g. locked in syndrome and motor neurone disease
* despite autonomy, patients do not have. right to demand treatment that may not be in best interest
* gov are in generally better positions than individuals to forsee and understand consequences
* vulnerable may be pressured to spare carers of the burden/ bullied into choosing death - cannot be safeguarded
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what is meant by an ageing population ?

3\.2 million people over 80 in the UK, expected to be 8M + by 2050 and 25% of the pop over 65

* sign of good healthcare but increases burden

impacts of ageing population

* increasing number of chronic conditions such as heart disease, Type 2 diabetes , arthritis and Alzheimers
* 1/6 80+ have dementia, 70% in care homes have dementia/ memory problems. Cost of care typically 100k +
* Cuts in social care leads to increase in A&E admissions due to increased falls, infections and dehydration
* older people more likely to live by coast whilst older live in cities

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Healthy life expectancy

Avg in UK currently 79.9 years for men and 83.6 for women but HLE 63.1 for men and 63.6 for women

HLE estimates years of ‘good’ or ‘very good’ health

years will major health issue increase

Gov aims to increase HLE by 5 years by 2035

* need for increased education and support around healthy life habits to reduce risk factors and more support for the vulnerable

vaccinations in the UK

NHS offers a schedule of free vaccines - majority being 13 childhood vaccines

* uptake of all 13 fell between 2018-19
* some (mumps and rubella) require children to be given multiple doses over time
* HPV offered to 12 and 13 year olds to in school to protect against cancers caused by high risk types of HPV
* most provide long term immunity but flu only lasts a year due to mutation rates
* 65+ receive flu free from NHS
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Covid-19 vaccine

* First person received Pfizer/biontech morning of dec 8 2020
* nearly 800k received first does by 31 dec, under 4 mil prediction
* 4th jan AstraZeneca in hospitals
* both designed to give two injections, 21 days apart but instead was followed with a booster 12 weeks later
* by oct 2021, 49 mil in the uk received one dose of the covid vaccine
* booster programme began in sep 2021
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Key issue: anti-vaccination groups

* claim that vaccines are unnatural and toxic, dates back to 1880s when anti-vaxxers in Leicester protested smallpox vax
* anti-vax social media had an increase of 7.7 million followers in UK and US in the pandemic
* investigation found hundreds of NHS staff members of an anti-vax fb group that compared vaccine to poison and were anti-mask
* labour proposed a new law to tackle the spread of fake anti-vax news

key issue: Wakefield and the MMR scandal

* 1998 controversial paper linking MMR vaccine with autism was published in the lancer by Andrew Wakefield
* paper proposed new syndrome the linked a novel bowel disease, autism and the MMR vaccine
* paper’s claims were proven false but still MMR uptake dropped
* childhood vaccinations reached a low of 79.9% until 2003/4
* Wakefield was struck off the UK medical register in 2010 but became prominent figure in anti vax movement

key issue: measles increase

* 2017, WHO declared UK eliminated measures after country reached high enough level of immunity to stop endemic transmission. lost status in aug 2019
* can be traced to falling levels of MMR between 1998-2004, children now at uni where high levels of MMR are reported
* 2019- 890 cases of measles reported in England

Why are vaccinations falling ?

RS of public health shows 2/5 parents exposed to negative vaccine propaganda

* urgency and seriousness of the illness is forgotten
* issues with timing and availability of appointments
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NHS long term plan for vaccination

* improving local coordination and support to improve immunisation conversation in low uptake areas.
* MMR check for children age 10 and 11 with GP and young adults who missed vaccination as children.

what is artificial intelligence ?

ability of a computer or other machine to perform cations thought to require intelligence

AI in medical diagnosis

* diagnosis of disease from medical imaging scans and microscope slides
* cancer can be diagnosed earlier leading to better outcomes
* assisting screening to determine the success of an embryo resulting in pregnancy
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AI in radiotherapy

uses patients CT scans and electronic health records to create a specific individualised dose

AI in virtual nursing

* virtual nurses are robots designed to monitor health
* wearable devices offering advice and guidance to patients in their own homes
* current: measures pulse, temperature, respiration and oxygen saturation
* could be implemented into 111

AI and robotic surgery

* robots developed to carry out routine operations which can possibly have a five fold reduction in surgical complications

AI and information services

NHS is working with Alexa to offer health information by voice search to reduce demand on health professionals and help impaired

what are the practical uses of AI in medicine ?

* earlier diagnosis: computers can be programmed to spot patterns earlier in disease progression
* data collection: improvement required in the collection, storage and quality of data as NHS is still reliant on paper files and IT systems are not open standard

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Pros and cons of AI

supports the delivery of the NH’ five year forward view and address health and wellbeing gaps

* con that public is weary of how their data is used and personal information required

what are the Francis reports ?

* Robert Francis QC led a public inquiry into poor care at Mid Staffordshire NHS Foundation Trust 2005-2009
* investigation of neglect of the trust brought to light by campaign group ‘cure the NHS’

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healthcare commission report

* found 400-1200 people could have died unnecessarily between 2005-8
* recurring problems included:
* call bells unanswered
* patients left lying in own urine/excrement
* food and drink left out of reach of patients
* patient falls being concealed from relatives
* too few consultants and nurses
* poor communication between staff and relatives

the first Francis report findings

* 2010- historic understaffing of nurses
* wards re-organised without necessary risk assessment
* nurses to healthcare assistants dropped 40:60
* poor nursing care main issue
* obsession with obtaining foundation trust status than meeting patient care

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the second Francis report

* 2013
* looked at how set up of entire health and social care system can help or hinder nurses and other staff to deliver good care
* culture of the NHS and impact on ability of staff to raise concerns

recommendations after the Francis reports

* staffing levels and skill mix
* protection of whistleblowers
* eradication of blame culture and bullying
* training and regulation of HCA
* recruitment, training and standards of registered nurses

Responses to the Francis report

* GMC- responded progress by insight into education, safety in practice environment and info sharing
* gov- actions to improve patient care, increasing openness and changes to regulation in hospitals
* NICE- asked by dep. of health and NHS England to create guidelines on staffing capacity
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Bawa-Garba case

* 18th jan 2011 6 year old Jack Adcock, who had down syndrome and a known heart condition was admitted with difficulty breathing, vomiting and diarrhoea
* admitted to Children’s Assessment Unit at Leicester Royal Infirmary following GP referral
* seen and assessed by Junior Dr Bawa-Garba, paediatric registrar in ST6
* taken to high court and on 4th nov 2015 found guilty of manslaughter on grounds of gross negligence

Bawa-Garba timeline

* Dr BG ordered X-ray that showed infection, available at 12:30 but unknown and not seen till 3pm. Antibiotics prescribed and administered at 4pm, affecting outcomes. Ward understaffed.
* failings in computer system reported high levels of CRP in blood due to infection and inflammation
* Dr BG stopped heart medication but did not record this, so his mother administered meds at 7pm
* Jack suffered Cardiac arrest at 8pm, Dr BG arrived as resuscitation was taking placed and called it off, mistaking for a DNR. resuscitation took place again. jack died at 9:20pm

Failings in hospital system of BG case

* Dr BG was carrying out the work of two doctors and the hospital was extremely understaffed
* senior consultants were not on-site and therefore Dr BG had no one to report to + not enough senior nurses
* Failure of hospital computer system and x-ray notification
* nurses did not notify jack’s deterioration
* administration of medication for Jacks heart meds was not carried out by Dr BG

legal battle of BG case

* after sentencing, Dr BG appealed her sentence :
* dec 2016 appeal denied by court of appeal, several doctors outraged due to lack of support for jun doctors and working conditions
* 12 month suspension from GMC, who actually applied to have her struck off only to be refused by medical practitioners tribunal service
* jan 2018 GMC appealed against MPTS in high court and were successful
* crowdfunding following public outrage so Dr BG could continue her fight
* Mar 2018 Dr BG granted leave to challenge this and won appeal
* nov 2018 Doctors association UK launched ‘learn not blame’ to create a better culture and learn from adverse events for fairness and openness for both patients and health professionals
* apr 2019- MPTS deemed Dr BG low risk to patients and was cleared to practice again
* feb 2020 - lack of patient contact meant employment at a lower grade and close supervision and imposed conditions
* jul 2021- MPTS ruled Dr BG is fit to practice without restriction

what is the Shropshire maternity scandal ?

* nov 2019, report from interim enquiry into failings at royal Shrewsbury and princess royal hospital in telford was leaked to press
* investigated deaths and injuries of babies at the hospitals from 1979-present, majority since 2000
* midwife Donna Ockendon led the review with more than 1800 cases examined after families were invited to contact the inquiry
* expanded from 23 families

Key patient in maternity scandal: Stanton-Davies family

* pregnancy flagged as high risk and mother Rhiannon should not have been on unit.
* midwives failed to monitor daughter Kate’s condition
* inquest ruled the death avoidable
* NHS review found systemic failings of former head of midwifery and midwives who retrospectively altered notes
* family wrote to Jeremy Hunt who ordered an independent investigation

findings of Hunt’s report

* biggest in history- clinical malpractice continuing unchecked for over 40 years
* at least 42 babies and three mothers may have died avoidably and 50 newborns sustained avoidable brain damage
* may involved significant errors
* findings of review published by Donna Ockendon in dec 2020

Malpractice in maternity scandal

repeated clinical errors inadequately followed up- lessons not learned

* families not treated with kindness or respect- staff referred to babies as ‘it’ and one babies body left to decompose weeks after post mortem

maternity scandal impact

* trust was ordered to pay 1 mil that was given for good maternity care
* two months after, maternity services were rated inadequate by CQC and were placed in special measures- weekly status reports were required from hospital bosses due to this
* jun 2020, west mercia police began a criminal investigation into the deaths of the babies to see if there was evidence to support a criminal case- ongoing
* aug 2020 emerged new areas of concern- suggests that failing leadership is perpetuating poor care and the trust has been rated inadequate on every measure

Causes of antibiotic resistance

* annual death due to multiple drug resistance could reach 10 million by 2050
* often customary for doctors to prescribe multiple antibiotics to combat a single infection
* drug-resistant bloodstream infections increased by 35% from 2013-17
* livestock is dosed with antibiotics
* GPs are pressured to prescribe antibiotics
* at least 20% of prescriptions are inappropriate
* GPs who prescribe fewer antibiotics have fewest satisfied patients
* 48% of GPs have prescribed antibiotics for coughs and bronchitis
* many fail to follow the course
* 40% believe it treats viruses

solutions for antibiotic resistance

* GPs prescribe more sparingly
* new guidance on appropriate prescription
* reduction in infections from surgery
* farming restrictions
* CCG reduce number of antibiotic prescriptions
* Public health eng push education of infection prevention

gov targets:

* 15% reduction in antibiotic use by 2024
* 25% drop in antibiotics in animals by 20210- refreshed 2021

improvement :

* consumption dropped 9% from 2014-18

drugs, therapies and research on antibiotics

Drugs:

incentivise pharma to research and develop by paying based on how valuable instead of amount sold

drugs undergo Health technology assessment by NICE to determine payment

Therapies:

Combination therapies involve using two or more drugs together to increase effectiveness of both drugs resistant to normal antibiotics

phage therapy - controversial, unused in west

Research :

Health and social care committed £32m to prescribe and identify patterns of resistance e.g. UCL uses AI to help tackle this to enable earlier diagnosis, treatment and dose

why is mental health important ?

studies show that 1/3 people experience mental health issues at some stage of their life.

in 2017, 1.4 million people were referred to NHS mental health therapy services

covid-19 impact on mental health

* lancet study revealed that by April 2020, mental health in the UK had deteriorated compared to pre-pandemic trends

key issue: perinatal mental health

* 1/5 women experience perinatal mental health problems (depression and anxiety)
* feb 2018, NHS England pledged 23 million to improve perinatal mental health services
* funding is part of a wider programme to provide access to 30000 women receiving specialist mental health care

Key issue : mental health and eating disorders

* estimated 30 million goes into funding eating disorder services per year
* feb 2019 announced patients with diabetes and bulimia will have access to therapy for social media and body image- fitting in with NHS long term plan to change mental health treatment with focus on children and younger people
* director for mental health claimed NHS England was on track to achieve their goal of treating 95% of all young people with and ED within one week for urgent cases and four weeks for routine cases by 2020/21
* report form Nuffield Trust found this had fallen to 70.5%

Key issue: access to services

according to NHS figures, in 2016-17 almost 6000 mental health patients were sent out of their local are to receive care- rise of 40% in two years

march 2019 - NHS would test a pilot scheme for patients in A&E presenting with mental health issues in order to ensure access to quick care

April 2019- NHS reported new and expectant months would have access to healthcare across England, first time that each of the 44 local NHS areas have specialist services

Key issue: NHS staff and mental health

oct 2020: further 15 million would be put towards strengthening mental health services for nurses, therapists, paramedics, pharmacists and support staff

* creates a national support service for critical care staff who may be most vulnerable to severe trauma
* funding nationwide outreach and assessment to ensure staff receive rapid access to evidence based mental health services
* developing wellbeing and psychological training

improving NHS mental health services

five year forward view for mental health (2016) added 1billion of funding for mental health

* NHS renewed commitment with a ring fenced investment worth at least 2.3 billion for mental health services by 2023/24
* Matt Hancock said in 2018 that it would potentially take a generation to achieve parity

inequalities faced by BAME staff in the NHS

* unequal representation amongst board members : 19.7% of the NHS workforce is made up of BAME groups, but only 8.4% of the board are BAME
* recruitment problems : lack of diverse representation at senior level produces barriers for BAME staff. White applicants are 1.46 x likelier to be appointed from shortlisting compared to BAME applicants
* less likely to be supported: BAME 1.22x likelier to enter formal disciplinary process. GMC’s fair to refer report found doctors from diverse groups did not always receive effective, timely or honest feedback due to difficult conversations being avoided. There is a culture of blame that creates additional risk for doctors who are seen as outsiders
* likelier discrimination : 15% of BAME stand reported experiences of discrimination from 2019 to 2020 compared to 6.6.% of white staff

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what is the NHS doing to address BAME discrimination ?

* the NHS people plan aims to increase BAME representation across the workforce, including at senior level to make the NHS more reflective of the patient population. Structural racism and unconscious biases need to be addresses for equality to be achieved
* NHS strives to engage further with staff and staff networks so that BAME staff can be heard and share experiences. Steps include establishing networks in webinars, attended by 240 BAME heads of staff networks

BAME patients

* **Death during childbirth.** Black women are five times likelier than white women to die in childbirth. Women of mixed ethnicity are also three times likelier to die and Asian woman are two times more likely.
* **Detrimental health outcomes.** The Marmot Report states that detrimental health outcomes associated with some ethnic groups are associated with their socio-economic, and sometimes economic, status.

impact of COVID on BAME

* disproportionate morality and morbidity: in the first month of the pandemic, 95% of NHS doctors who died were from BAME backgrounds, explained by health conditions, age and socio-demographic factors
* Staff scared to raise COVID concerns: formal disciplinary processes are more common amongst BAME groups in comparison to their white counterparts

NHS response to BAME COVID concerns

* NHS employers published guidance for NHS organisations to ensure appropriate measurers to mitigate risk - considers whether adjustments to work should be made or whether redeployment is possible
* bespoke health and wellbeing offer that includes rehab and recovery for BAME colleagues
* 4M was provided by UK research and innovation and the national institute for health research to fund six research projects investigating links between covid and ethnicity

public health measures: sugar tax

UK soft drinks industry levy:

* introduced In April 2018
* drinks with over 8g of sugar per 100ml have to pay a tax of 24p per litre
* drinks with 5 to 8g of sugar per 100ml have to pay 18p per litre
* the gov say income generated from the sugar tax would be invested in school sports and breakfast clubs - not true
* forecasted to raise 1.37bn over four years

effectiveness of the sugar tax

* raised awareness of the impacts of excess sugar intake
* over 50% of manufacturers reduced the sugar content of their drinks
* purchasing of soft drinks remained the same, but the amount of sugar in the drinks fell by around 10 %

key concerns regarding childhood obesity

* 2018/19 that 22.6% of children aged 4-5 were overweight, with a third of 10-11 year olds
* caused by improvements to home entertainment, increased junk food contribute
* obese children are more likely to become obese adults
* increased risk of developing type 2 diabetes- 745 children and young people were treated for in 2017/18
* number of children with type 2 diabetes increased by 47% in the last 5 years.

public health measure: local council trials

* gov established a plan of action on childhood obesity, announced that 5 local councils would be given 100k a year over three years to aid in combatting childhood obesity- blackburn, Bradford, Darwen, Nottinghamshire, Lewisham and Birmingham, who would all try new programmes to help shape future national policies
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public health measures: more opportunities to exercise

* in jul 2019, gov announced the school sport and activity action plan to allow children to do 60 mins of activity each day.
* Dept of education committed 2.5M for more training for PE teachers + weekend and holiday openings. Sport England would give 2M to create 400 new after school clubs in disadvantaged areas

public health measures: Leeds examples

* Leeds has become the first UK city to see a drop in childhood obesity due to a decade-long strategy
* through the charity Henry, parents were offered an 8 week programme involving lessons on healthy food and meals for families

public health measure: fat tax

* controversial discussion around a fat tax due to connotations of judgement, punishment and blame
* supporting arguments include:
* obesity causes the government the most
* leads to health problems such as type 2 diabetes, heart disease and cancer
* money spent on these conditions could be better spent elsewhere
* could reduce consumption and encourage healthier eating
* opposing arguments:
* mental/medial health issues: people with depression have a 58% increased risk of obesity
* most disadvantaged people face greatest obstacles
* hard to eat healthy when stressed
* price manipulation is seen as a form of control
* likely to affect those on low income the most
* denying autonomy is seen as a step backwards