“We can’t do this”: A mission impossible to meet the NHS performance targets

As we head into 2019,  the media coverage has intensified with stories of the ‘mayhem’ due to the coming cold snap and the looming crisis in the NHS and the race to combat the “toughest ever” winter crisis and the pressures on the hospitals to meet their targets. This comes on the back of the BBC story, asking public to check how their local hospitals are performing against some key targets . We are now also told that the ministers and the NHS England chief are at loggerhead over targets and demands for specific improvements linked to £20.5bn cash boost for the NHS.

The pursuit of efficiency and use of performance measures  has been a hall mark of the NHS in the last few decades. The management by targets   approach in the NHS has yielded some positive results but cases of ‘hitting the target but missing the point’ are also common.  For instance, in my own research, I have systematically documented a range of unintended consequences  of the ambulance response time targets and have found out that the targets continue to play a significant role in driving behaviours and cultural perpetuation of key values. In my recent opinion piece, I have shown how the ambulance services have been failing to meet their new performance standards faced with various other challenges.

Evidence from the last winter points out the difficulties in meeting the A & performance  standards.  Media stories highlighting delays  on the part of ambulance crews arriving at the scene including deaths of the patient waiting for an ambulance further add to the narrative. Some of these arguments have been rehearsed earlier but in my view there are two key issues which need our attention. These include: the funding situation for the NHS organisations, and the worsening staff shortage exacerbated by the Brexit and current immigration policy.

Address the funding-demand gap

The sustainability of an underfunded and overstretched NHS has been a matter of much  debate , analysis and scrutiny  including emotive calls about unnecessary deaths caused by the funding crisis. The National Audit Office  in its most recent report has concluded that “the additional funding, aimed to help the NHS get on a financially sustainable footing has instead been spent on coping with existing pressures”.

The funding crisis has also been the subject matter of media reports and an ongoing inquiry by the Parliamentary Select Committee. Different sectors of the NHS are facing specific issues. In my research, I have argued  the case for the ambulance service that doing even ‘same with less’ is proving difficult for individual ambulance trusts.

The Carter Efficiency Review , published in February 2016, highlighted concerns about wastage and ‘unwarranted variations’ across different NHS organisations. While it identified areas of improvement and potential savings of £5 billion, it also raised fundamental questions over the need for significant investment in the sector. However, in the current climate of financial austerity, it is difficult to see how its fifteen recommendations can be implemented in order to achieve the desired savings. Notwithstanding any disagreements over the about the scale of the problem, it’s quite clear that the NHS is under serious strain.

Improve staff situation

The NHS Five Year Forward View made a categorical commitment to support a diverse, modern and healthy workforce. However there are huge challenges on this front, not least the additional uncertainty the Brexit ‘deadlock’ brings. A joint report by the Nuffield Trust, Health Foundation and The King’s Fund,  published in November 2018, has issued a stern  warning that the current staff shortages of 100,000 is likely to rise to 250,000 by 2030 and could be more than 350,000 if the “emerging trend of staff leaving the workforce early continues and the pipeline of newly trained staff and international recruits does not rise sufficiently. This should not come as a surprise since the staff shortage crisis was highlighted in the draft NHS Workforce Strategy published in December 2017 for the first time in twenty-five years on back of the worst NHS crisis.  Again, if we were to look at the figures for the ambulance and allied services, out of the 17,000 nurses, midwives and allied health professionals (AHPs) who went on to the professional registers between 2015 and 2017, only 7,000 of them have joined the NHS. The Strategy sadly points out that the primary reason for staff leaving the NHS is the ‘growing pressure’ they are experiencing in the workplace.   Shortage and retention  of staff, accompanied by the highest sickness absence rates in the NHS, dominate the ambulance workforce agenda.

Media reports  are on the rise highlighting cases of harassment and bullying of the NHS staff as a consequence of pressure of meeting performance targets with one in four staff   have reported to have experienced bullying in some way, costing  around £2 billion annually to the NHS. The latest NHS Staff Survey has revealed some shocking statistics about the ambulance staff showing them worst for discrimination and equal opportunities, worst for illness due to work-related stress, worst for team working and worst for staff engagement. Last year, Guardian reported a story that the hospital bosses felt ‘humiliated and bullied’ when they were forced to chant ‘we can do this’ over A&E targets by a senior NHS official in a performance review meeting. CQC Inspection Reports highlighting similar concerns for poor staff morale due to the pressures of meeting performance targets are also not very uncommon.  The issues around dignity and staff retention are still significant owing to the continuing work intensity.

Conclusion

As we enter the cold winter period, there are further signs that the NHS is witnessing an all year round-365 day crisis and the pressures felt by the system are not confined to the busy winter months. A latest report  by Nuffield Trust has suggested that it is “unlikely that this winter is going to be significantly better for patients and the NHS than last year”. NHS figures continue to show that hospitals in England are ‘badly missing’ targets despite mild weather and low flu levels. An independent analysis on the impact of the £20.5 billion extra funding to the NHS has reported fears that it is likely to be used-up by the on-going issues such as the ageing population, pay rises, hospital effects and the rising cost of drugs.

Additionally, the uncertainty resulting from the postponement of the vote on the Government’s EU Withdraw Treaty in the Parliament and the dangers of a ‘cliff-edge’ Brexit is making the already grim situation worse. Such an uncertainty at the onset of what many believe would be a worst winter for the NHS, coupled with the impact of a harsh Brexit on the NHS workforce is likely to have a devastating impact on staff morale.

It is thus becoming clear that the current approach to deal the crisis with emergency cash injection is proving ineffective. It is time to take a fresh look at the targets and to address the fundamental issues of the funding gap and workforce welfare if NHS organisations are to have a fighting chance to meet their performance targets. Unless that happens, it very much looks like a ‘mission impossible’!

The problem with using psychoanalysis on children

File 20181217 181905 bwlz18.jpg?ixlib=rb 1.1
shutterstock

Michael Richards, Edge Hill University

Children with problems or problem children? That is the question often asked by parents and teachers alike. If a child is naughty in school, are they a “bad” child or are they facing mental ill health?

Most analysis focuses on children being the problem – a highly individualistic take which resonates with Sigmund Freud’s theory of psychoanalysis. This is a theory which dates back well over a hundred years, with strong roots in focusing on childhood problems influencing adult behaviour.

Psychoanalysis developed over the course the 20th century, and although the approach has been dismissed by many, we live in a society where there is still an obsession with “psychoanalysing” children. This inevitably labels children as a problem rather than recognising the problems that affect wider society.

What drives behaviour?

Psychoanalysis specifically relates to Freud’s own school of thought, which believes a person’s behaviour is determined by early childhood experiences. According to Freud, a person has instinctive drives within the unconscious that influences their behaviour – unconscious material can be found in dreams and unintentional behaviour.

Freud’s focus was on specific sexual stages of development that influence our personalities as we develop in life. At the oral stage of development for example, (from birth to one year) Freud implied that oral stimulation could lead to an “oral fixation” in later life – such as sucking your thumb in times of stress.

Psychoanalysts believe that therapeutic interventions can bring the effects of this unconscious material into consciousness with the aim of resolving these issues.

Questioning Freud

Freud’s psychoanalytical theory, and other versions of psychoanalysis, are problematic for so many reasons. For a start, Freud’s theories are based on the “unconscious mind”, which is difficult to define and test. There is no scientific evidence for the “unconscious mind”. And it would be difficult to say who would be qualified to make assumptions about this when nobody really knows what the unconscious mind is.

For children, this means teachers, social workers, nurses, psychiatrists and other professionals make assumptions about them based only on their present behaviour – and without considering any wider social issues. This makes psychoanalysis ignorant of difference and diversity, and over-generalised. Particularly so when directed at young children – given that personality and behaviour can change over the course of someone’s life.

There’s no such thing as a ‘good’ or ‘bad’ child. Shutterstock

Research also shows that “naughty” behaviour in schools can be because children lack aspirations and a drive to do well. This can stem from many factors such as low self-esteem and high anxiety – as well as growing up in a low income household. Children who are in care, children with disabilities and children from Afro-Caribbean backgrounds are also more likely to be excluded from mainstream school if they live in deprived areas.

Stop blaming children

It is relatively easy to criticise the use of psychoanalysis, particularly when people are “psychoanalysing” without understanding what it is or isn’t. In this sense, Freud and the general idea of psychoanalysis has become a part of our language – and our analysis of trying to make sense of human behaviour.

And this is not without reason. Freud’s theories still play a role in the teaching and learning of many counsellors, psychologists and psychiatrists today, despite facing much criticism since its inception. Indeed, many types of therapies emerged post-Freud – including transpersonal therapy which is a more humanistic take on therapy – and many people have benefited enormously from these approaches.

But ultimately, the problem with psychoanalysis is that the focus is still primarily on the individual being the problem. And in the case of children, to keep focusing on them as the problem, while ignoring wider, social problems is dangerous.

Labelling a child as a ‘problem’ from a young age can have detrimental consequences. Shutterstock

Psychoanalysis does also not fully acknowledge the power of labelling and stereotyping that takes place within schools and in other aspects of a child’s life. It is almost like there is reassurance in focusing on a “problematic” child because there is always a box to tick, which might provide some idea of the “problem” and then result in a resolution.

But it is impossible to do this properly while ignoring the major issues children face in their world. This includes a lack of resources due to high poverty rates, alongside the increasing levels of mental health issues such as self-harm. Individuality can of course not be ignored but neither can the wider social problems that children face. This is important because ultimately it is these external factors that have the power to really influence the mental health and well-being of children.The Conversation

Michael Richards, Lecturer in Applied Health and Social Care, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Weight monitoring during pregnancy could help save lives

File 20181122 182059 1nkjo71.jpg?ixlib=rb 1.1
Shutterstock

Hazel Flight, Edge Hill University

There are times in a person’s life when specific events can have long-term implications on their future health. Pregnancy is one of those times – when major and dramatic changes occur within a woman’s body composition in a short period of time.

A key element of a healthy pregnancy is appropriate weight gain. Maternal obesity is thought to be one of the most common factors in high-risk pregnancies. It can cause short and long-term health risks to both mother and child, an increased birth weight and problems with delivery.

It is thought that 20% of pregnant women in the UK are obese, and due to the current obesogenic environment it is likely that this proportion will increase.

Obesity in pregnancy can cause infants to be predisposed to develop childhood obesity, metabolic syndrome and diabetes. For the mother there is also the risk of pre-eclampsia, miscarriage and gestational diabetes.

To combat this, there have been calls for women’s weight to be monitored throughout the course of their pregnancy. This is something which has not been carried out consistently in the UK since the 1990s (when there was a lack of clinical evidence to suggest it was worthwhile).

But we know now that body composition measurements can help predict maternal health and pregnancy outcomes. This monitoring throughout pregnancy may also have an influence on the birth weight of the baby, which in turn is a key determinant of short and long-term health conditions.

Midwives have a unique opportunity to provide advice regarding appropriate nutrition to the women in their care, and health promotion and education are considered among the most important activities they perform. However studies in the UK, Sweden and Australia conclude that many struggle to provide this advice.

One reason for this is that midwives do not have clear guidelines regarding what weight a woman should gain throughout her pregnancy. The National Institute of Health and Care Excellence (NICE) are currently considering a target of 16kg for women of a normal weight and 9kg for those who are obese.

Eating for how many?

It is important to remember that weight gain during pregnancy is not the sole issue with regard to the future health of the baby. If a baby has low weight gain following birth the risk of chronic disease later in life is increased and the child can also be undernourished and suffer stunted growth.

And while the focus is often on obesity and excessive weight gain, there are also serious issues at the other end of the spectrum. Women who do not gain enough weight and are not consuming enough calories are more at risk of giving birth preterm to children with a low birth weight. Babies born under 2.5kg are less likely to survive, and those that do also have an increased risk of long-term health conditions.

The current dietary reference value for a pregnant woman is an extra 200 Kcal per day in the third trimester only. This is all that should be required in order to maintain the healthy development of the foetus.

Counting 200 calories. Shutterstock

The myth that pregnant women are “eating for two” encourages them to feel they can eat whatever they want. The right information about how much and what they should eat during pregnancy is still not reaching many women – potentially putting their health, and that of their unborn babies, at risk.

So who should be providing this information? The weight loss organisation Slimming World has been commended for supporting women to eat healthily and monitor weight increase in pregnancy.

But there also needs to be advice provided to how to increase weight for those who are underweight. Alongside information regarding adequate and appropriate nutritional intake, there is a need for specialist support and education within this area. This could be a valuable role for a nutritionist as part of the care provided to women during their pregnancy.

Management of a healthy weight and subsequent weight gain in pregnancy is becoming increasingly difficult to maintain within modern society. The current advice from NICE is that weight and height are measured at the pregnant woman’s first appointment – but not regularly throughout the pregnancy.

Yet pregnancy is a time when women often have an increased nutritional awareness and the motivation to do what is right for themselves and their baby. Regular weight monitoring would be an effective way of helping them achieve this – while they are hungry for information on how to be as healthy as they can be.The Conversation

Hazel Flight, Programme Lead Nutrition and Health, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Child obesity is linked to deprivation, so why do poor parents still cop the blame?

World Obesity Federation., CC BY

Robert Noonan, Edge Hill University

Childhood obesity has risen ten-fold over the past 40 years. In the UK, roughly 30% of children are overweight or obese. Obesity rates are much higher among children living in deprived communities. In England, there is a clear trend: the wealthier a child’s family is, the more likely the child is to be a healthy weight. And those who are a healthy weight during childhood are much more likely to be a healthy weight in adolescence.

In 2006, then Labour leader and prime minister Tony Blair argued that many public health problems, including obesity, can be solved by getting people to change their lifestyles. But strong evidence from behavioural economics research and weight-loss trials shows that advocating personal responsibility is destined to fail in the long-term.

The fact remains that behavioural interventions alone – such as the NHS five a day and Change4Life campaigns – do little to address child obesity across society, because healthy food is not always easily accessible. In fact, these types of approaches widen socioeconomic health inequalities. Findings from my latest research drive this home: childhood obesity rates in Liverpool – one of England’s most deprived cities – increased by up to 3% between 2006 and 2012.

Lessons from Liverpool

For our study, we analysed data from the National Child Measurement Program (NCMP), which measures the height and weight of children within state schools across England. We examined the data of 25,905 children aged four to five years and 24,220 children aged ten to 11 years, recorded between 2006 and 2012, in order to track changes in childhood obesity and socioeconomic health inequalities over time.

Liverpool is the sixth largest city in England, and up until 2016 it was ranked as the nation’s most deprived, with over 90% of Liverpool’s 470,000 population living in areas of high deprivation. Across the six-year duration of the study, children who lived in deprived communities became overweight or obese at a greater rate than children living in less deprived communities.

As public health and other services across England continue to have their funding cut by central government, it’s more important than ever that the nation takes a new approach to tackling child obesity, and reduce inequalities linked with poor health.

A better way

For too long, behavioural interventions have been used to prompt people – especially parents – to take responsibility for individual instances of child obesity. For example, the national social marketing campaign Change4Life aims to prevent child obesity, by educating and informing families about the benefits of being physically active and eating healthily. And the NCMP informs parents if their child is overweight by means of a letter, reinforcing the idea that it’s the parent’s responsibility to address their child’s weight.

Meanwhile, little attention is paid to the policies or the social and environmental conditions which also shape healthy (or unhealthy) behaviours. Research points to inequality as a primary factor which prevents people from making healthy choices. For example, many deprived communities are “food deserts”, where affordable or high-quality fresh food is hard to come by.

Deprived communities also have few opportunities for physical activity, and typically live in areas where there are lots of fast food outlets. If we take Liverpool as an example, the city now houses over 600 fast food outlets – a figure which has risen by roughly 10% since 2014.

Too great a temptation. Shutterstock.

There is quite a lot of evidence showing that children are more likely to be overweight or obese if there are fast food outlets near their home or school. To reduce access and remove temptation, some councils in England have suggested banning fast food outlets within 400 m etres of schools. But councils’ hands are tied, as they dont’t have the powers to stop new takeaway outlets being built.

People are the product of their environment, and in modern society, the default choice for many people is the unhealthy choice – and for some, the only choice as eating healthy has been shown to be more expensive. To address this major problem, government policies need to address public health priorities. The healthy choice needs to be just as easy as the unhealthy choice, and there needs to be a level playing field, in terms of the accessibility and pricing of decent food.

Placing the responsibility on children and families, without changing their economic and physical environment, will do little to tackle health inequality and reduce weight-related health problems in society. Instead, the government needs to step in and, through policy, create communities which promote and enhance healthy choices and lifestyles. Only this will ensure that the default choice for most people is the healthy choice.The Conversation

Robert Noonan, Senior Lecturer in Physical Education and Children’s Physical Activity, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Why you shouldn’t take antibiotics for colds and flu

File 20181112 83564 5ho4bz.jpg?ixlib=rb 1.1
And don’t infect everyone else in the office either. Shutterstock

Carol Kelly, Edge Hill University

Winter is well and truly on its way. For many, this conjures up images of log fires, mistletoe and festive feasts. But it can also mean cold, damp mornings, short hours of daylight and the dreaded cold and flu season.

Tickly throats, headaches, fevers and generally feeling rotten are the warning signs that many of us fear. Pressures of work and personal commitments often lead people to seek a quick fix from their GP or other healthcare professional. This usually takes the form of antibiotics.

Evidence suggests the use of antibiotics is on the increase, which is a cause for concern as the overuse of antibiotics has been linked to antimicrobial resistance. This is the ability of microorganisms – such as bacteria and viruses – to evolve so that antimicrobials (antibiotics and antivirals) become less effective at killing or working against them.

Antibiotic resistance results in standard treatments – such as many of the commonly prescribed antibiotics – becoming ineffective. And this leaves people who need antibiotics for serious infections vulnerable.

This issue has been recognised as a problem on a global scale in a UK government commissioned review. These findings led to the National Institute of Clinical Excellence (NICE) publishing quality standards to help clinicians when prescribing antibiotics to slow the rise in antimicrobial resistance.

Antibiotic expectations

The Cochrane review, on which I worked, found that many vulnerable patients have an increased risk of developing microbial resistance. This includes people with chronic respiratory illness – many of whom have “rescue packs” which include antibiotics at home. These repeat prescriptions are often issued without enough education to support their use or highlight their drawbacks – so unnecessary prescribing practices continue.

Beliefs and expectations by patients, healthcare professionals and society have been found to be the main drivers of the overuse of antibiotics. From a patient’s perspective, the desire to get better is often more important than any external considerations such as publicity campaigns. And for healthcare professionals, the greater good of society occurs outside the immediate consultation and is therefore often overlookedalong with existing evidence. This breeds a cycle of expectation and self-interest which serves both clinician and patient but neglects wider societal issues.

It is possible, then, that much antibiotic prescribing, particularly in the flu season, is driven by these expectations – from both patients and healthcare professionals. But this is not unique to antibiotic prescribing. Our previous research found similar behaviours with oxygen therapy. Despite emerging evidence and guidelines, poor prescribing and administration of oxygen therapy persists – and it is often given routinely for breathlessness to patients.

A medical priority

A UK parliamentary health and social care committee report on antimicrobial resistance has called for the issue to be regarded as “top five policy priority” for government – stressing the need to support the pharmaceutical industry to develop new antibiotics.

How Brexit will affect this investment and commitment is unclear. But there remains an urgent need to promote responsible and appropriate prescribing through education, research, guidelines and campaigns.

Current UK prescribing levels are reported as double that of other countries such as Sweden, Netherlands and the Baltic States. This presents a challenge for primary care and hospitals who need to reduce both the number of antibiotics prescribed and the length of time that they are administered.

Antibiotic efficacy

A recent government report has called for the use of rapid diagnostic testing to inform all antibiotic prescriptions. This approach should take the guesswork out of prescribing antibiotics by testing for blood markers that signify the presence of infection. Findings from a large trial based in the UK are expected soon.

Sometimes though, the prescribing of general use antibiotics is not only expected, but cheaper and easier. So it will require a concerted effort to promote responsible prescribing and educate all healthcare professionals, patients and the public to refrain from using antibiotics.

So as winter approaches, rather than rushing out to your doctors at the first sign of a sniffle, try and ride it out. Get lots of sleep, keep stress to a minimum and up your fluid intake – all of which have been shown to help in the treatment and staving off of colds and flu. It’s also worth being extra vigilant with hand washing to help keep those germs at bay and stop them from developing into something more nasty in the first place.The Conversation

Carol Kelly, Reader Respiratory Care, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Winter pressures and the NHS Ambulance Services: ‘Doing more with less’ is not an option

ambulances queuing outside A&E at a North West hospital

Paresh Wankhade, Professor of Leadership and Management and Emergency Services Management Expert discusses the issues the Ambulance Service faces as winter approaches in his latest Comment blog:

With each passing year, the winter crisis puts a massive strain on the NHS ambulance resources with huge bottlenecks in the transfer of patients into the hospital Accident and Emergency (A&E) wards. In 2017, media carried several reports which highlighted delays on the part of ambulance crews arriving at the scene, including deaths of the patient waiting for an ambulance. Some of these arguments have been well rehearsed and have also prompted emotional debates and the cries of “52 weeks of the year crisis” in the Parliament.  I have highlighted four issues which in my view are the key flash points for ambulance services to deal with such recurrent crisis.

Address the funding-demand gap

The sustainability of an underfunded and overstretched ambulance services is though well recognised, but remains unresolved. The National Audit Office reported that between 2009-10 and 2015-16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million (average year-on-year increase of 5.2 per cent), and income for NHS ambulance trusts’ urgent and emergency care activity increased by 16 per cent from £1.53bn to £1.78bn between 2011-12 and 2015-16, but ambulance activity over this period (NHS ambulance calls and NHS 111 transfers) rose by a massive 30 per cent. This is accompanied by significant shifts in the demand with only 10 per cent of 999 callers having a life threatening emergency despite the average annual increase of five to six per cent in ambulance demand.  Doing even ‘same with less’ is proving difficult for ambulance trusts, something I have argued in my recent piece.

 

Move away from response time targets

Response time targets have been historically used to measure ambulance performance. Since July 2017, performance of NHS ambulance trusts is being benchmarked against four new national standards, based upon patient’s condition, now enshrined in the NHS Constitution.  However, during May-September 2018, ambulance services in England failed to meet  all the standards. A recent Parliamentary Report concluded that ‘ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the most appropriate response for patients’ (p.5).  Another view that ‘commissioners, regulators and providers still place too much focus on meeting response times” reported in the National Audit Report (p.8) is deeply worrying.

Our research points to similar conclusions. We have systematically documented a range of unintended consequences  of response time targets used by the ambulance services.  We have also explored the relationship between cultures, performance measures, and organisational change to understand how organisational culture is perpetuated and found the targets to be a significant factor impeding the process of change. Ambulance services have embarked on the drive for ‘professionalisation’ but our latest research suggests that as ambulance work continues to intensify, ‘issues around dignity, staff retention and the meaning of work are becoming ever more challenging’.

 

Introduce fines/penalty for hospital delays

Ambulance handover delays to hospital A&E departments can have serious implications for patient safety and reduce available ambulance resources. The 30 minute cycle (handover and readiness for next call) is proving difficult to resolve. NAO  figures suggest that in 2015-16, only 58 per cent of hospital transfers met the 15-minute expectation in 58 per cent of cases as against 80 per cent in 2010-11, and only 65 per cent of ambulance crews were then ready for another call within 15 minutes. There are inconsistencies on the part of commissioners to penalise hospitals that do not adhere to the guidance of 15-minute transfers in absence of a fining regime. A quality indicator for measuring hospital performance in meeting the transfer-time target has not yet materialised, notwithstanding the recommendations of the Committee of Public Accounts.

Improve efficiency and productivity

The Carter Efficiency Review, published last month, highlighted concerns about huge variations in the delivery of ambulance services. It suggested potential savings of £300m a year by cutting unnecessary ambulance transfers, along with further £200m through use of more efficient models of operations and procurement.  But the review also raised fundamental questions over the need for significant investment in the ambulance sector. The shortage and retention  of paramedic staff coupled with high sickness absence rates continue to be a problem, an issue highlighted in the draft NHS Workforce Strategy. However, the review raises the clear need for investment since one of the recommendations to reduce high conveyance rates is likely to have cost implications. This will also require high quality staff engagement.

 

Conclusion

There are no easy fixes and addressing the winter pressures will necessitate strong and visionary leadership by ambulance chiefs and cooperation from other health care partners, in a political climate dominated by Brexit. A ‘whole systems’ approach is crucial to deal with this crisis. The Dalton Review called for successful leaders to act as a ‘systems architect’ to use their entrepreneur skills to explore innovative organisational models, as set out under the NHS Five Year Forward View. The Carter Review necessitates ambulance leaders to make right business and spending decisions which will impact the NHS. Devising an effective public education campaign to minimise misuse of ambulance resources and managing public expectation, will be a good starting point.

Crime and nourishment – the link between food and offending behaviour

File 20180926 48644 1wzsgtk.jpg?ixlib=rb 1.1
tiverylucky/shutterstock

Hazel Flight, Edge Hill University; John Marsden, Edge Hill University, and Sean Creaney, Edge Hill University

It is well known that eating a balanced diet is of vital importance for maintaining good health and well-being. It is also one of the great social pleasures of life. Yet, far too many young people in prisons are consuming a poor diet, lacking in nutrition.

Alarmingly, research suggests over half of food items available for purchase in some prisons in the UK and the US are “high in fat or sugar”. It has also been suggested that in the US, prison food has been described as “scant, joyless, and unsavoury”. But it doesn’t have to be like this. Sant’angelo dei lombardi in Italy is said to have one of the best fed prisons in the world, where prisoners work to produce organic fruit and vegetables and leave healthier than when admitted.

Poor nutrition can impact on concentration and learning and may result in episodes of violent or aggressive behaviour. In prison, a bad diet can also contribute to increased rates of poor mental and physical health compared with the general population.

To tackle this problem, a new UK government strategy aims to provide young people with healthy eating advice on arrival in prison. Inmates up to the age of 21 will be provided with nutritional guidance so they can make “informed choices” about their diets.




Read more:
Why nutritional psychiatry is the future of mental health treatment


Poor diet, aggression and impulsivity

The amount and nutritional value of food available in prisons and the dietary choices prisoners make has a significant influence on the quality of a prisoner’s life. Consuming highly processed and sugary foods can lead to sudden peaks and troughs in the amount of glucose in a person’s blood. This can cause fatigue, irritability, dizziness, insomnia and is even a risk factor for depression – particularly in men. It has been shown that a diet of whole foods can offer protection against depression.

Deficiencies in vitamins and minerals can lead to a number of issues. For example, low levels of iron, magnesium and zinc can lead to increased anxiety, low mood and poor concentration, leading to attention deficits and sleep disturbance. Omega 3 is required to improve cognitive functioning.

Recent government policies have recognised the problem of additives and the high sugar content of food, with the introduction of the sugar tax and moves to address the use of colourings, which have been found to have a negative effect on behaviour and hyperactivity. A recent example of the UK government’s willingness to intervene in the purchasing decisions of young people is the outlawing of energy drink sales to under-16s.

The types of problems associated with a poor diet, such as aggression, attention deficits and hyperactivity can make impulsive behaviour more likely. Studies have shown that “high levels of impulsivity are connected with high and stable levels of offending”.

Addressing the problem

Lucy Vincent – a freelance journalist with a background in both food and fashion – has started a campaign to address the need for better food in UK prisons. She believes that decent nutrition has the power to positively impact self-esteem, health, learning and development. Young people in prison are likely to have struggled with these issues and providing a better diet is an important step in improving their emotional health and well-being.

But there are obvious difficulties in improving the diets of young offenders. For example, Public Health England suggests that providing a balanced diet costs £5.99 per person, per day. Yet some prisons have food budgets as low as £1.87 per person, per day. There are obvious economies of scale to take into account, but providing a balanced diet for young offenders would still be a costly exercise – at a time when other parts of the prison service are starved of funds.

With experienced prison officers leaving the service and their remaining colleagues protesting over unacceptable levels of violence, improving the diet of young people in prison will be difficult to achieve.

But if the UK is to come close to breaking the cycle of reoffending, it needs to meet the basic needs of young people in prison and respect the basic human right of adequate nutrition. Government advice for young inmates is one thing, but those in prison need to have healthy food to choose from if they are to have any hope of staying healthy in jail.The Conversation

Hazel Flight, Programme Lead Nutrition and Health, Edge Hill University; John Marsden, Senior Lecturer in Counselling and Psychotherapy, Edge Hill University, and Sean Creaney, Lecturer in Psychosocial Analysis of Offending Behaviour, Edge Hill University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Potatoes are out of favour – but they have strong roots in a healthy lifestyle

File 20180821 149466 qfczdr.jpg?ixlib=rb 1.1
shutterstock.

Hazel Flight, Edge Hill University

Potatoes are apparently far from being flavour of the month. Rejected by young people and “clean eaters”, sales are plummeting. But what has the potato done to deserve being treated so distastefully?

Reports claim that millennials prefer rice and noodles, and think that potatoes will make them fat. According to The Grocer magazine potato sales have decreased by 5.4% in the last four years, while sales of rice and noodles have risen by 30%.

But the potato has a proud history. One of the most common and versatile root vegetables, it was first cultivated by the Inca Indians in Peru over 7,000 years ago. Brought to Europe in the 16th century, potatoes have been associated with population surges and increased global urbanisation. There are now as many as 2,000 different varieties being grown in over 160 countries.

Yet today it seems we crave the quick and easy, avoiding anything that requires time or preparation. Potatoes are apparently seen as neither exotic, convenient or healthy.

So why did a once favoured food find itself pushed aside? Well let’s examine the evidence before it is judged guilty. In its defence the potato has all the requirements to form part of a healthy balanced diet.

In 100g of steamed potatoes, you’ll find just 100 calories, no fat, no sodium, no cholesterol, and no gluten. Instead, you’ll get nearly half your daily dose of vitamin C, more potassium than in a banana and plenty of vitamin B6, fibre, magnesium and antioxidants.

Yes, there is starch, which can increase insulin sensitivity – but it can also improve blood sugar control, digestive health, nutrient absorption and satiety (fullness), help curb inflammation in the body, boost immunity and improve blood circulation.

The case against potatoes often seems to rest on accusations of high calorific value. But it is not the actual potatoes which bring the calories, it is the method of cooking.

And yes, potatoes are high in carbohydrates, but these are necessary for long term energy. Many do not know the difference between simple and complex carbohydrates. Potatoes are complex carbohydrates which are a necessary part of our everyday diet.

People often listen to the latest diet information and react by thinking that certain food groups are not good for you. In fact, a person requires foods from each nutrient group in order to maintain optimal health. Eating potatoes cooked appropriately in moderation is simply not harmful.

Potatoes are also classified as a high glycemic food, but if eaten as part of a diet which includes high fibre foods such as lentils, beans, nuts and other vegetables, the sugar spike can be counteracted.

Hot stuff. Shutterstock

A lot of the potato’s PR problem may simply be about portion control. It seems that once we start to eat a bowl of chips or crisps, we find it impossible to stop until they are gone, and all of their salty calories have been consumed. Boiled or baked potatoes on the other hand are very rarely eaten to excess.

When the chips are down

But with rises in obesity, we become obsessed with following the latest diet craze – where usually at least one of the main nutrient groups are significantly decreased or eliminated. As part of this, potatoes have become taboo.

In the 1970’s potatoes formed a staple part of the everyday diet. In the decades since, according to the National Obesity Forum, which compared the habits of 4,000 UK households from 1980 to 2012, eating habits and diets have been getting steadily worse.

This has been mainly due to the introduction of processed foods and ready meals and falls in line with the commencement of the obesity crisis in children. Another reason may be due to more exotic lifestyles. With foods from around the world more readily available, alongside the increasing number of takeaways, the potato has lost some favour. But in our desire to save time and money we may actually be forgetting a key aspect – our overall health and longevity?<!– Below is The Conversation's page counter tag. Please DO NOT REMOVE. –>The Conversation

Potatoes deserve to be given another chance. People need to consider the way that they have been cooking and consuming this wonderful vegetable. There is no reason to cast them aside. For a nutritious vegetable which will power up your performance – look no further than the humble spud.

Hazel Flight, Programme Lead Nutrition and Health, Edge Hill University

This article was originally published on The Conversation. Read the original article.

Forcefully holding children for health procedures causes avoidable stress

File 20180501 135844 1h2guq8.jpg?ixlib=rb 1.1
Shutterstock/Seventyfour

Lucy Bray, Edge Hill University and Bernie Carter, Edge Hill University

When children go to hospital they enter a strange place. It’s an unfamiliar building that sounds and smells unusual, full of strangers and intimidating equipment. This can be overwhelming and can make them feel small and anxious. Children cannot always find a way to say that they are scared or worried about having a simple procedure such as an X-ray or blood test so they show their feelings through crying or refusing to have the procedure done.

This does not always happen, as many parents and professionals are skilled at using creative methods such as play, books and technology, to prepare and distract a child and help them have a good experience of having a procedure.

However, we know from our work that a child who says “no”, “stop” or “wait” is not always listened to and a child kicking out, crying or trying to wriggle away is not always taken as a sign by parents or professionals to stop.

In our study, we observed 31 procedures undertaken in a children’s hospital and interviewed the health professionals, parents and children. In many of the cases the child was held in order to “get the procedure done quickly”.

Often, especially with young children, a parent or health professional will hold a child to make sure the procedure is completed. This may be a parent giving their child a “tight hug” on their knee or in some cases may involve a child having their arms and legs held by parents and health professionals. This holding of children to get procedures done is not something that happens once in a while, it happens often within healthcare. The majority of health professionals (81%) in our international questionnaire reported that children are held for procedures frequently or very frequently.

Children get scared during some procedures. shutterstock/Photographee.eu

‘Upsetting and stressful’

Most parents will remember holding their child for a procedure at some stage in their lives, whether this was for an immunisation, examination or procedure. In many cases parents feel that being with their child is important and being the one to hold them feels supportive. Parents want to do “whatever it takes” for their child. But some parents are “surprised” at being asked to hold their child and can find it “upsetting and stressful” if they end up having to hold them forcefully.

Our research shows that professionals can also feel upset. One professional told us: “Sometimes you think you might have gone a little bit too far, you do think …‘I don’t like the fact that I had to hold her so tight’”. Most importantly being forcefully held can cause a child to be scared of coming to hospital and having procedures in the future. They can even experience psychological trauma and harm.

Is the procedure urgent?

Each situation that may lead to a child being held is unique and presents a particular set of circumstances. In some cases, when a child is very poorly or unwell and a procedure or treatment is urgent then it may be justifiable to hold a child who is resisting and asking for it to stop.

But the decision to hold a child who is sobbing and clearly upset is more difficult to justify if the procedure is not urgent. Health professionals and parents make a quick on the spot decision whether to hold a child to get a procedure done. We found that parents and health professionals can become too focused on getting a procedure done and neglect to take a minute to think if there is a different way.

Each child has a right to express their dissent through words like “stop” or by pushing people away. When this happens they should be listened to – not simply ignored and held more tightly.

The Rights of the Child

Children have rights, acknowledged by the United Nations Convention on the Rights of the Child. The convention outlines how children have a right to be protected from harm and the right to an opinion. More importantly, they have a right for this opinion to be listened to and taken seriously.

Professional guidance states that holding a child for a procedure should be a “last resort” after all other means of preparation and distraction have been tried. Our work shows that holding children for non-urgent procedures is not always a last resort. It continues to be a part of everyday practice that impacts on everyone involved. Our research is looking at how to develop resources and new interventions to help avoid this.

The ConversationChanging practice requires each and every one of us to challenge how taken for granted the use of holding is. Using creative methods to prepare children for procedures and supporting children throughout can do a great deal to reduce the need for forceful holding and reduce the stress and trauma which can be experienced by children, parents and health professionals.

Lucy Bray, Professor in Child Health Literacy, Edge Hill University and Bernie Carter, Professor of Children’s Nursing, Edge Hill University

This article was originally published on The Conversation. Read the original article.

Sore throats and false nails – the ambulance call-outs that cost millions

File 20180405 189816 16eq9co.jpg?ixlib=rb 1.1
Brian A Jackson/Shutterstock

Keegan Clay Shepard, Edge Hill University

Ambulance call-outs are increasing, resulting in services operating under enormous, and probably unsustainable, pressure. While most calls do need an emergency response, far too many don’t. A study of 300 consecutive emergency ambulance arrivals to an accident and emergency (A&E) department in London, England, found that only 54% of the patients legitimately needed an ambulance.

The tabloid press are fond of reporting daft ambulance call-outs, like one to revive a dead pigeon, and another to see if McDonald’s had run out of chicken nuggets. Funny though they are, these kinds of calls put a strain on services and take paramedics away from emergencies that are genuinely life threatening.

These calls can also be truly disheartening for paramedics who see themselves as health professionals who are there to treat people and save lives. Research has found this to be a common concern among paramedics who are obliged to respond to patients no matter how silly they perceive the call to be. In my ongoing study of the perceptions of patient safety in three English ambulance service NHS trusts, an emergency operations centre supervisor told me of her frustration:

I have questioned one drunken man’s request for an ambulance because he had a sore throat, and this is when there were 23 calls waiting to get through, and I was angry about that.

Her anger at situations like these is both understandable and common, with one paramedic involved in my study discussing his concern for other patients with legitimate emergencies, when having to respond to calls they find to be ridiculous:

You laugh, but when I started I got a call-out to a girl because of false nails. She’d been playing with her boyfriend, bent her nail, bent back and the nail come off … And while I’m dealing with that, there could be a cardiac arrest somewhere, someone could be stuck under a lorry.

Not an emergency. CRM/Shutterstock.com

As well as tying up resources that could be used to treat genuine medical emergencies and increasing the waiting times at A&E departments, these calls can be expensive for the ambulance services. In the UK, each call costs about £7, £180 if an ambulance is sent to treat a patient and £233 if the patient is brought to the emergency department. Given that a significant portion of calls are seen as not requiring an emergency response, this can add up to millions of pounds every year.

24/7 culture

Although the rise in the rate of demand for ambulance services, at 6.5% each year, is relatively recent in the UK, inappropriate call-outs have been documented in research going back at least two decades. One study proposed a couple of reasons why patients phone the emergency services for conditions that could be treated in primary care, including difficulty getting a GP appointment and a perception that they will be treated more quickly.

The high number of inappropriate calls could also be attributed to a 24/7 culture, where people expect immediate treatment for any condition, no matter the severity. A paramedic in my study considered it to be a generational problem, with millennials making the most of these calls:

It’s a great generation, but young people today don’t understand what the services are for, and we didn’t have this problem as bad some decades ago. They will call us for just about anything.

Public awareness

With demand projected to increase in coming years, it is clear that the ambulance services need to address the issue of inappropriate call-outs soon. Many things can be done to lessen the pressures of demand and to allocate the resources of the ambulance services more efficiently. However, to reduce the number of silly call-outs, it’s clear that public perception of what the ambulance service is for, needs to change.

Awareness could be spread through educational campaigns, using social media to reach the patients online, such as South Central Ambulance Service’s 999 Misuse Costs Lives campaign, which informed patients of when it’s appropriate to dial 999 and when it’s appropriate to use a different service, such as a GP clinic.

The ConversationAlthough changing people’s expectations is essential, a more holistic approach will also be necessary – one that gives patients appropriate access to alternative care settings, such as their GP or walk-in centres. Until this is done, some people will continue to rely on the ambulance service to treat minor ailments.

Keegan Clay Shepard, PhD Student and Graduate Teaching Assistant, Edge Hill University

This article was originally published on The Conversation. Read the original article.