Sunday, 24 September 2017

Mirror, mirror on the wall, is the NHS still the best health care system of all?

Last Tuesday was the 32nd anniversary of the 1985 magnitude 8 earthquake in Mexico, an earthquake that killed 10,000 people and left 30,000 injured. Mexico is one of the most seismically active places on Earth.  Last Tuesday was also when Mexico experienced a 7.1 magnitude earthquake that has killed over 300 people. The country has an elite team of rescuers known as ‘the moles’ and the search for more survivors goes on. Unfortunately the death toll is likely to rise as rescue efforts become recovery activities. And yesterday Mexico had another earthquake, this time a 6.1 magnitude. My thoughts, and I am sure many others too, are with all those effected by this dreadful disaster.

Last Wednesday I was reminded of the devastation a different earthquake had caused. This was the magnitude 7.6 earthquake that shook the Kashmir region along with parts of Pakistan, India and Afghanistan on October 8th, 2005. This earthquake killed 80,000 people and over 4 million people were left homeless. Unlike Mexico whose health and general infrastructure is better prepared to deal with such disasters, the death toll in Pakistan was so high in part, because there were no drugs, medical equipment or associated relief infrastructure. My colleague, Dr Ayaz Abbasi was there at the time providing help to those caught up in the disaster.

Last Wednesday he told stories of that time as part of his presentation at the Wrightington, Wigan and Leigh (WWL) NHS Hospital Trust Annual Public meeting. He told of his despair of treating patients in crude conditions, sewing up wounds with ordinary cotton, and without the benefit of any anaesthesia being available. It was an emotional re-telling of his experience. Dr Abbasi is now the Clinical Director of the Accident and Emergency services at WWL. The A&E Department is one of the best in Greater Manchester, and indeed is consistently in the top 10% of all high performing emergency departments across the NHS. He was justifiably proud of the team he works with and what they had been able to achieve.

Dr Abbasi was equally proud of the wider NHS – he urged the audience to recognise what a fantastic service it was and that there was no other health care system in the world that was able to provide the level and quality of health care to people in the way that the NHS does, and does so consistently. He wasn’t blind to the problems that the NHS faces. The demand for care is constantly increasing, a growing part of the population is getting older, presenting with more complex needs, and health care professionals can do more with technology, pharmacology and interventions than they have ever been able to do. When the NHS was first created it had a budget of some £437 million (roughly £15 billion at today’s value) - now the budget is some £124 billion a year, and even this huge resource doesn’t always go far enough.

In his talk, Dr Abbasi recognised that we needed to reshape the way in which NHS services are delivered. The current Government is committed to ensuring this happens through the development of new care models and treatment in the community and closer to people’s homes. However the change required is going to take time. There are 3 times more doctors and 4 times more nurses working in hospitals than in the community. Partly this is a consequence of the way the training and education of health care professionals still remains highly centralised. I fail to see what added value those responsible for the commissioning of education and training of health care professions, bodies such as Health Education England, really bring to ensuring the workforce needs of local health economies are appropriately met.

Last week, I received an invitation to join other members of the Nursing Midwifery Council (NMC) Thought Leadership Group in a couple of weeks’ time to review the responses to the consultation on what the future graduate nurse might ‘look like’ and what the educational programme to achieve this might also ‘look like’. Of course whilst it’s a real privilege to be able to help shape the future health care workforce in this way, I am slightly challenged by the notion that the NMC is just one of many different regulatory bodies determining the scope of professional practice for the various different health care professions. I am not convinced that such tightly differentiated approaches to regulation and the establishment of individual boundaries of care is helpful of even necessary. Dr Abbasi in his talk rightly acknowledged the contribution the whole team made to ensuing high quality, safe care was available to all patients whatever their need. Perhaps the various heath care regulators could learn something from the way in which integrated and inter-professional health care is being delivered in the WWL A&E department. 

And like Dr Abbasi, I think that the NHS is a wonderful institution, even with all its challenges. As a health care system it provided superb care for both the Kevin’s in Scotland, my Mother in Wales, Mark, Daniel, Jack and Christine in England, and of course my brother Christopher, who 10 years ago yesterday, lost his battle with a long standing illness, and died. For me, his passing will always feel premature. Rest in peace Christopher. 

Sunday, 17 September 2017

CSE and CSA and the need to create portfolios of prevention

Like many of my fellow bloggers, I am intrigued by words and how words are used. I touched upon the relative importance of words in communicating emotions and attitudes in my blog post last week. I'm also interested in the etymology of words. Etymologies are not definitions of particular words, but can provide explanations of what our words meant and how they might have sounded from as far back as 2000 years ago.

Last week I was looking for the origins of the word ‘portfolio’ (it was a temporary distraction from actually constructing my research portfolio) – and the word ‘portfolio’ comes from the Italian portafogli, as in portare ‘carry’ and foglio ‘leaf’. What I didn’t know until I searched was that ‘portfolio’ was one of 60 words introduced into the English language in 1713. Here are a couple of sentences containing some of the others – Dr T was a self-devoted sparkler of a man, with a horselaugh and a fuzzy beard. He had built a machinelike clothespress thinking he was creating an orrery, which although a great piece of work would not be going into his portfolio!

However, I did come across 2 news items last week that absolutely sat within my research portfolio. The first of which was the research published by the Centre for Mental Health. This showed that mental health problems experienced by the UK workforce had cost employers some £35Bn last year. This equates to £1300 for every employee in the UK economy. At any one time 1 in 5 working people will have a mental health difficulty, but the issues are not straightforward as they might first seem. A large proportion of the £35Bn cost comes from the reduced productivity caused by people continuing to go to work when they are mentally unwell. Such behaviour costs businesses’ twice as much as paying for sickness absence arising from mental health problems.

Sadly some people will never get any help and some will lose their job because of mental health problems. For others, being at work can be an important part of their recovery journey. The good news is that many organisations are now taking the mental health and wellbeing of their employees seriously. In my University, we have long had in place support for our students who may be experiencing mental health problems, and over time have extended this focus to staff as well. From my own recent experience of mental health problems. I know the current approach is on prevention, promoting a healthy workplace as well as being appropriately supportive when such measures are not quite enough. However, whilst mental health issues are increasingly talked about more generally, there is still a degree of stigma attached to those experiencing a mental health problem. The result can be some individuals being reluctant to ask for help or speak about their experiences. The sound of silence can be very damaging.

Shattering the silence really encapsulates the issues in the 2nd portfolio item to capture my attention last week. Last Friday was #PurpleFriday, a day to raise awareness of both Child Sexual Exploitation (CSE) and Child Sexual Abuse (CSA). Although closely entwined, there is a difference. CSE involves exploitative situations, contexts and relationship where young people (or a 3rd person) receives something (money, alcohol, gifts, affection) as a consequence of them performing and/or another or others performing in them, sexual activities. CSA involves forcing or enticing a child to take part in sexual activities, whether or not the child is aware of what is happening. Sexual abuse is not always perpetrated only by males, women can also commit acts of sexual abuse, as can other children and young people. 

The NSPCC recently reported a contemporaneous (and somewhat disturbing) evidence base of the prevalence of cases of CSE and CSA in the UK. Although comprehensive, it is an evidence base likely to be incomplete in terms of capturing and understating the prevalence of the both issues, because for example, the way in which cases get reported and the hidden nature of the abuse. Despite this lack of incomplete data, we do know that number of recorded sexual offences against under 16 years olds in 2015/16 was 37,778, a figure that has doubled over the last 10 years. It is not just sexual abuse or exploitation that should concern us. The impact on a child of emotional abuse or neglect is also likely to be significant. 

In the UK, there has been a rise of the number of children being on a child protection plan or register for emotional abuse, a rise from 23% in 2006 to 35% in 2016. As devastating as these statistics are, the increased number of children on such plans and register’s might also reflect an increased awareness of the importance of ‘breaking the silence’ and reporting concerns to professionals. The NSPCC report provides evidence that the wider public have a growing understanding of the ways in which abuse can be prevented. Their research showed that 56% of those asked believed that abuse and neglect could be prevented. The belief that abuse can be prevented is likely to be the critical first step to all of us taking action and saving a child from experiencing and living with abuse in any of its forms.

Sunday, 10 September 2017

The Zika virus: an organism at the edge of life

Although now retired, the psychologist, Professor Emeritus Albert Mehrabian still works as a researcher at the University of California, Los Angeles. He is probably best known for his research into body language and non-verbal communication. His book ‘Silent Messages’ (first published in 1971) can still be found on Amazon, and is absolutely worth a read. Ironically for someone whose work is so well known and is still hugely influential, it is often misunderstood and misused.  In particular, it is the work arising from a 1967 experiment, which has come to be the most misused over time – most people will know the outcomes of this research as the ‘so called’ 55%, 38%, 7% rule in communication.

That is: 7% of meaning is in the actual words that are spoken, 38% of meaning is in the way those words are said and 55% of meaning is in the accompanying facial expression. If one stops and thinks about this for a moment it is obvious that this cannot be so!  If it were, wouldn’t we be able to understand 90% of what is said in a foreign language just by seeing the person talk, or understand most of what is said on TV with the sound turned off? Mehrabian has long been at pains to say that his work was only about the way feelings and attitudes are being communicated; outside of this specific use, the 55, 38, 7 equation doesn’t hold true!

I recalled Mehrabian’s work as I was thinking about the way some research outcomes become completely embedded into our collective thinking, even, when as in Mehrabian’s example, it is for the wrong reasons. Many researchers are to blame in this regard. Last week I had an interesting discussion with a colleague whose role at the University involves communicating research outcomes and tracking the impact of the research as it gets translated into practice. He had a constant battle with the words used by many academics in describing the research undertaken, methodology used and the results. His complaint was that often the language used is not accessible to non-academics and what was often missing was the answer to the ‘so what’ question – you have done the research, but what difference or benefit will it have for me?

It was a valid observation. However, most academics write for a specific audience. Sometimes this will be for peer reviewed journals where methodological, epistemological and scientific narratives are standard and expected, or they are writing for commissioners of research and will be required to conform to a widely accepted way of communicating information and ideas in order that the bid can stand being scrutinised and judged against other similar bids. Such conventions can, at times, result in information content that is impenetrable to all but a limited group of other academics, and/or the message becomes over simplified and misunderstood.

As always, a middle ground can be found. Last week I thought the on-line BBC News site did a good job reporting on the outcomes of research into the Zika virus. Zika is a virus that people get through being bitten by an infected mosquito. Most people have very few symptoms, but the disease poses a serious threat to babies in the womb. I guess most of us will have seen pictures of affected babies - their abnormally small heads are the outward sign of the disease. Zika-based infections have been linked to severe birth defects in almost 30 countries. Although not now seen as an international medical emergency, the World Health Organisation (WHO) is closely monitoring its spread.

The BBC story focused on new research published in the Journal of Experimental Medicine that reported the Zika virus can selectively infect and kill ‘hard-to-treat’ cancerous cells in adult brains. Whilst human trials are not likely for at least another 18 months, the laboratory-based research shows the potential of injecting the virus into the brain at the same time surgery is performed to remove brain tumours. There are many types of brain cancer, but the most common tumours are Glioblastomas. These account for 12-15% of all brain tumours and they are very difficult to treat. Glioblastoma is most common in adults aged 45-75, and affects more men than women.

The tumours are fast growing, spreading through the brain very quickly, making it difficult to see where the tumour ends and the healthy tissue begins. So surgery, radiotherapy and chemotherapy may not be enough to remove these invasive tumours. Glioblastoma stem cells continue to grow and divide, creating new tumour cells. It is healthy stem cells that the Zika virus attacks in babies, whereas adult brains have very few stem cells. This means in the case of adults, Zika treatment should only destroy the cancer-causing brain stem cells without causing damage to other healthy brain cells. 

When I first read the story, I wondered who had first thought of doing the research. The science is clear, the connections obvious when pointed out, but I suspect beyond most of us. So perhaps my colleague was right – we need to find greater opportunities to talk, listen and share ideas in order to grow our shared understanding of the possible. Its sounds like a great starting point for everyone in the research community! For me, as today is World Suicide Prevention Day, I hope there are lots of researchers working on how we reduce the numbers of those who want to end their lives in this way.

Sunday, 3 September 2017

Flights of Fancy - the Challenges of Creating an Appropriate Workforce

25 years before I was born, Amy Johnson started her solo flight from England to Australia. It was a journey of over 10,000 miles. She finally landed some 19 days after leaving the UK. It was a fantastic achievement. She became the first women to fly solo over that distance. Today Emirates (there are other airlines), will do the same journey in 23 hours, and a business class ticket will cost you just £3160. These days it would probably be impossible to replicate exactly Amy’s journey. She put down in places that have now become very troubled and dangerous – Turkey, Iraq, Iran, Pakistan and Syria. Indeed, I am not sure if Aleppo in Syria still has a functioning airport. 

Amy Johnson was an inspirational women – not only did she undertake what must have been fantastically difficult journeys during the 1930s, but she was also an engineer of great repute. She was twice President of the Women’s Engineering Society (WES). WES is both a charity and a professional network of women engineers, scientists and technologists. They have a vision of the UK becoming a country where women are as likely as men to choose to study and work in engineering. To this end WES works collaboratively with educators, employers and influencers in creating a diverse engineering community. However, achieving this vision is a challenge.

At my University, we have many examples of the kind of outreach work that can introduce girls to study engineering and think about science, engineering and technology as a career choice. Someone who is as inspirational as Amy Johnson, is our Professor Haifa Takruri-Rizk. For over 20 years she has being researching and teaching in the fields of electronics, mobile networking, and the organisational cultures and workplace practices that support women in science, technology and engineering fields of practice. Her outreach work is very successful and applications by young women to study in these areas have held steady and begun to grow. But there is more that needs to be done.

Encouraging more women to study and work in these areas is critical for the UK's future economic prosperity. In the UK, the proportion of young women studying engineering and related subjects has remained more or less at 16% compared to places like India where around 30% of students are female, and these subjects represent over 30 of all university programmes taught. WES notes that less than 10% of the UK engineering workforce is female compared to countries like Latvia, Bulgaria, Cyprus where 30% of the workforce is female. The shortage of engineers in the UK is now becoming critical and it is estimated that we need to double the number of students and increase the current workforce by 60,000 people with engineering skills. It’s a challenge.

Of course it’s not just in the engineering workforce where gender inequality and representation is to be found. In my professional field of health care, gender balance has been a long standing issue. In medicine, there are some signs of change but it is slight. There are 281,440 doctors registered to practice in the UK. Of these 128,137 are female, but they are outnumbered by men in every field of practice other than General Practice, where there are slightly more females practising as GPs than men. The number of women entering medical school is still slightly higher than men (52%) but there has been a steady decline in overall numbers of women in training over the past 10 years.

In nursing the problem is reversed. The number of men in nursing remains stubbornly low. Only 12% of registered nurses in the UK were male – and this figure has remained constant over the past 5 years. Likewise for those considering nurse education and training, there are just under 12% male student nurses; a figure that has remained constant over the past decade. Just like in the case of engineers, encouraging children to think about nursing as a career and identifying strong role models is key to addressing the issues. And there’s the rub. Try and generate a list of famous and iconic nurses and you almost inevitably go back a long way in time – Florence Nightingale, Mary Seacole, Edith Cavell and so on, even my favourite, Virginia Henderson, whose legacy in terms of influencing contemporary nurse education and practice, is unlikely to be known outside of the profession. If one tries to identify male role models it becomes even harder. My 2 favourites are Walt Whitman and Phil Barker – but again, with the exception of poetry lovers, these are names that are unlikely to be  known outside the profession. 

Whilst social media is helping, the emergent nurse leaders of today, (and there are many to be found in the world of Twitter, Facebook and so on), don’t have the wider recognition that someone like Amy Johnson did all that time ago. It’s a challenge, and one that all members of the workforce, men and women need to rise to if we are ever going to change things.