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By Jennifer Dixon, London School of Hygiene & Tropical Medicine

Health and healthcare policy have been a matter for the separate administrations in Scotland, Wales and Northern Ireland since devolution in the late 1990s. While there have been many similarities in the policies the four UK countries since then, there have been some very high profile differences.

For example, developing competition between providers has been championed in England but rejected in Scotland, Wales and Northern Ireland. The split of purchasing from the provision of care was reversed in Scotland and Wales, but kept in England and Northern Ireland. And in Scotland and Wales prescription charges were scrapped, and free personal social care made more widely available in Scotland.

But what effect, if any, have these policy differences had on overall performance? To find out, we at the Health Foundation along with the Nuffield Trust commissioned researchers from the London School of Hygiene and Tropical Medicine and the London School of Economics to measure performance against 22 indicators, including mortality rates (avoidable deaths), life expectancy and ambulance response times. Drawing on largely publicly available data up to 2011-12, and in some instances 2012-13, the subsequent report revealed some interesting results.

Of the four nations, England performed marginally better in a number of areas including mortality rates, life expectancy and ambulance response times. However, nurse staffing levels were lower than in the other three countries. In Scotland, waiting times for planned surgery were down (similar to England) as were ambulance response times.

Wales on the other hand did not do as well when it came to waiting times, which have deteriorated since 2010, particularly for common procedures such as hip or knee operations. The difference between the typical waiting time for one of these procedures in Wales in 2012-13, for example, was 170 days compared to just 70 in England and Scotland.


Northern Ireland has improved on most indicators, but MRSA mortality rates still remain higher than in both England and Wales.

What this means and for whom

Four major messages come from what we found. The first is for the public. On the national indicators analysed, there were improvements across all four countries in investment, staffing levels, amount of activity provided and health outcomes. This is good news, although there is clearly a marked variation in performance within each country.

The second is for politicians. The main message here is that while the overall set of policies is producing results, no one policy cocktail consistently produces faster improvements over another, despite all the rhetoric.

This may be because there are many more similarities in policies than differences across all four nations. Or that where there are policy differences, they haven’t yet made enough of a difference to show up in the indicators. Some humility then is needed by politicians of all political stripes; how the health systems perform seems to be influenced far more by a bigger set of forces.

However, the data suggests that there may be two exceptions, both of which can be influenced by politicians. One of these is funding: the study period coincided with a large growth in public funding for healthcare, which can be associated with the improvements seen in performance. However, between 2010-11 and 2012-13, Wales saw a reduction in spending, potentially the reason for the lengthening of waiting times.

The second exception is targets and performance management. The data suggest that clear targets and strong performance management – as in the case of waiting times and rates of hospital acquired infection – produce results. This seems to be the case in Scotland, where waiting times on a range of indicators show marked improvement, particularly over the last five years. And part of the reason why, in Wales, performance against the less-stringent targets for waiting times has dipped since 2010, may not just be because of changes in funding, but because of less emphasis on the English-style tight performance management.

This isn’t a message for politicians to let rip with a vast number of targets and go for a heavy grip. Too many targets demoralise staff, cause collateral damage (other local priorities pushed aside) and can lead to stressed staff altering the figures.

The third major message in the report is for local staff: the managers, nurses and doctors. More than anything, it looks as though performance of the health system is down to you. Our study looked closely at the performance of one region in England (the north-east) relative to Scotland, Wales and Northern Ireland, because it was more similar on a number of characteristics than England as a whole. In the north east of England, a combination of faster funding growth, plus local conditions, seem to have produced the most marked reduction in mortality over the last two decades.

The fourth message is for the treasury. Probably due, in part, to devolution, it is becoming harder to compare data across the four countries over time, as all four countries decide to define data differently. If achieving value for money in public services is an objective of the treasury, isn’t it time to exert some leverage to expect all four countries to collect and count data in the same way, as well as do it their own way?

The issue that looms large is the impact of large scale reforms of the health system of the type we have seen in England, with the implantation of the Health & Social Care Act. Received wisdom is that the disruption it has caused will produce a dent in the trend for improvement in England relative to the other UK countries. But we’ll have to wait for the next instalment of the study to find out.

The Conversation

Jennifer Dixon is Chief Executive of the Healthcare Foundation charity. She is also She is also a trustee of NatCen Social Research and a member of the Care Quality Commission (CQC) board.

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

Offers like these are banned in Scotland

The Scottish Parliament passed the Alcohol Act in October 2011. A key part of the legislation was a ban on multi-buy promotions — 3 bottle of wine for £10, for example. Now the first research into the effect of the ban has revealed that the amount of alcohol sold in Scotland fell by 2.6% in following year. In a report prepared by NHS Health Scotland and the University of Glasgow. the researchers found that the introduction of the legislation could be associated with a 4% drop in the quantity of wine sold in supermarkets and off-licences, almost 4.5m bottles. While there was little evidence to show an impact on beer or cider sales, the Act was linked with an 8.5% drop in the number of pre-mixed alcoholic drinks sold.

NHS Health ScotlandMark Robinson, public health information manager at NHS Health Scotland, welcomed the results, pointing out that the findings showed that “the Alcohol Act has had the intended impact of reducing alcohol consumption in Scotland by placing restrictions on how alcohol is displayed and promoted. We know that some retailers responded to the multi-buy discount ban by selling individual bottles of wine for £3.33 instead of offering three bottles for £10. However, the incentive for people to buy more alcohol than they may otherwise have bought was removed and wine sales decreased.

“Although these effects are welcome, alcohol consumption in Scotland remains high and a large proportion of alcohol is still sold at relatively low prices. There is good evidence to show that the positive effects of the Alcohol Act would be enhanced by minimum unit pricing, which would prevent the sale of cheap, high-strength alcohol.”

Alex Neil MSP Health Secretary

Alex Neil MSP
Health Secretary

Dr Jim Lewsey, senior lecturer in medical statistics at the University of Glasgow, explained that similar declines were not observed in England and Wales, where the Alcohol Act does not apply, and the possible impacts of other factors, such as changes in income and alcohol prices, were taken into account. “This provides evidence that the effects were associated with the Act and not some other factor,” he said.

The report was welcomed by Health Secretary, Alex Neil. He believed that Scotland was “moving in the right direction but our consumption and harm remain at historically high levels. It was always our intention to introduce minimum pricing alongside the multi-buy ban, which will save lives and reduce alcohol-related harm and the costs associated with it. We believe minimum pricing, agreed by Parliament, backed by expert opinion and now vindicated by this recent court ruling, is the most effective pricing measure to address the availability of high-strength low-cost alcohol.”

BMA chairman Dr Hamish Meldrum

So, much to the surprise of some, BMA members have voted to strike. In a pretty good turnout as these things go, doctors have said that yes, they would take industrial action short of a strike, and yes, they would strike too.

The issue, of course, is pensions – the UK government wants to change the NHS pension scheme; the BMA and its membership don’t want it to, hence today’s ballot result.

So will our men (and women) in white coats (and scrubs) be digging out the braziers and manning the picket lines? Well, at the time of writing (Wednesday morning) we don’t actually know. The BMA’s national council is pondering where to go next in a special meeting likely to go on until this afternoon.

What is most unlikely is a strike in the sense that it is usually understood. The exact details are doubtless being worked out, but, in the lead up to the ballot, the BMA said it would involve things like not treating non-urgent cases, such as elective surgery. Doctors would be at work as usual, but would basically be doing things that couldn’t wait – dealing with emergencies, carrying out vital treatment, that sort of thing. Technically – legally – this could be construed as “strike” action, hence the second question on the ballot paper to protect those taking part.

So how has it got to this point?

When it comes to doctors’ pensions, there are a lot of figures – some conflicting – to consider. The BMA, for example, says the government’s proposed changes will mean that doctors will have to pay more, for longer, to get less of a pension at the end. The UK government on the other hand points out that the average consultant retiring at the moment has a pension of more than £48,000 per year and a tax-free lump sum of more than £140,000 – and says that under the new scheme, a 40-year-old consultant will have to work an extra two-and-a-half years to get the same.

As a freelancer who pays around 10 per cent of earnings into a private pension every month (with the hope of receiving, ooh, tuppence farthing a week if I retire age 95), you might not expect me to have much sympathy for well-paid public servants, including doctors and, say, senior NHS managers, who will, even under the new scheme, retire much better off than the rest of us (unless we’re judges or MPs, but that’s an argument for another day).

On the other hand, writing for BMA News, a weekly magazine for doctors, obviously I hear the arguments on the other side as well. For example, the BMA points out that the NHS pension scheme is in rude financial health; that it was reformed in 2008 and that doctors agreed to up their contributions then to make sure that the scheme was sustainable, not just for doctors, but for the lower paid, including domestic staff and porters.

The union (and we mustn’t ever forget that the BMA is a union, much like Unison or Unite, and as such has its members’ interests at heart) is also fed up because the government has pressed ahead with taking increased contributions from doctors’ pay packets without agreement. The Scottish government, incidentally, has said that it doesn’t agree with the UK government action on pensions, but is going along with it anyway for its own financial reasons.

So who has the right of it? Well it’s easy to sneer at senior public sector workers (including doctors) for their “gold-plated pensions”, and yes, even after the government’s reforms, the NHS scheme will offer a better deal than you can get in the private sector. It’s easy, too, to point out that private companies have been closing their final salary schemes and replacing them with much less generous terms. It’s also easy, particularly in the current financial climate, to say that doctors should think they’re bloody lucky to have a relatively highly paid and interesting job, with rather more job security than many (although that could well change if some of the UK government’s other proposals come to pass).

But surely that kind of carping is looking at things the wrong way. Why should we grudge other people having good pensions, just because we don’t? Shouldn’t the solution be to work to ensure that everyone has a great deal in retirement, rather than insist that all join the race for the bottom? And don’t say we can’t afford it: Britain remains one of the richest countries in the world, although sometimes you really wouldn’t think it.

Doctors are angry – today’s ballot results show that very clearly. Perhaps the rest of us should get angry as well.

– BMA ballot results in full.

 

 

Tough bananas

Tough bananas. Picture: Wonderlane

So we’re having another go at integrating health and social care – about time too: it’s been a good eight years since LHCCs transformed into CHPs or CHCPs, so we must be due for a change of acronym by now.

Step up Health and Social Care Partnerships (HSCPs? HaSCPs?). These new bodies will replace CH(C)Ps, and are at the heart of the Scottish Government’s vision for an integrated health and social care service, initially for adults, but local areas will be free to be a bit more wholesale about it if they want.

The key difference is that the new organisations will be the joint responsibility of the NHS and local authority. This will be written into law – so if, for example, a local authority doesn’t want to delegate budgets, then tough bananas, they’ll have to. NHS boards and local authorities will be required to produce integrated budgets for adult health and social care services, and partnerships – working with the third and independent sectors – will be responsible for delivering new nationally agreed outcomes.

It should mean – as the consultation document published today says – that there is “a system of health and social care in which resources – money and people’s time – can be used to best support the individual at the most appropriate point in the system – regardless of whether what is needed is ‘health’ or ‘social care’ support”. In other words, there will no longer be any excuse for a quarrel over whether something is a “health” bath, or a “social care” bath, with the bill going to the “loser”.

Personally I really, really hope this works, but forgive me for sounding cautious. Who was it who said a second marriage was a triumph of hope over experience? Well that’s kind of how I’m feeling. Back in 1999 when local health care co-operatives were formed I thought they sounded a great idea: essentially voluntary groupings of GP practices, LHCCs were supposed to work together with local authorities and the voluntary sector to deliver a wide range of primary and community health services.

Now, much as LHCCs are often seen through rose-tinted spectacles, believe me, they weren’t perfect: far from it. While some were fabulous, and achieved great things for their local communities, it was generally acknowledged that development was patchy, at best. Major concerns included a lack of clout – they weren’t statutory bodies – and, despite the fact that they had GP practice involvement baked in, as it were, there were still fears about a lack of clinical engagement.

Five years later we saw the launch of CH(C)Ps – again, I was quite excited (I don’t get out much). These were statutory bodies, so they actually had some financial rights (albeit only to health board community budgets) and they had more involvement from the wider primary care team – in other words, it wasn’t just GPs.

There was however, in hindsight, a lack of prescription from the centre – in an attempt to allow local flexibility, to cope with Scotland’s varying needs in terms of geography and demography, health boards were actually pretty much allowed to develop CH(C)Ps in their own way. Again, some were great; others less so. Indeed, the rows and contortions around development of some of the “partnerships” in Greater Glasgow in particular will probably make a film at some point, or at least a BBC Scotland radio drama. A lack of clinical engagement with CH(C)Ps, especially from GPs, has been a particular issue, across Scotland.

And now we have HSCPs – and I really, really want to be excited again. As we’ve seen, the consultation document published today tries to address some of the major issues with both LHCCs and CH(C)Ps – including making GPs and other clinicians a bit more involved in the process. But will it be enough?

Nicola Sturgeon is under no illusion that it’s a big task, and is keenly aware that this is not the first time that this marriage has been attempted. In evidence to the Health and Sport Committee, she said that previous lack of success was in part due to “too much local choice about the degree and extent to which integration happened”.

She added: “We had no genuine joint accountability; we still had separate silos of accountability. I do not blame health or local government for that because, in truth, on different occasions one or the other will have been more responsible, but the separate lines of accountability have meant that it is too easy to pass the buck.”

The current consultation makes it abundantly – and rightly – clear that legislation is only a part, indeed, quite a small part, of the change which will have to happen if this new attempt at integration is to be a success. Cultural change is a phrase that is often bandied about, but it’s apt here. Creating truly integrated care will involve a great big melting pot in which professional, organisational and other differences will have to be put aside. And, put bluntly, that involves changing people, which isn’t easy.

Nicola Sturgeon - current systems make it "too easy to pass the buck"

Initial reaction from the relevant trade unions has been cautiously positive, with both the BMA and RCN in Scotland welcoming the document’s recognition of the important role to be played by clinicians. Indeed, RCN Scotland director Theresa Fyffe sounds almost optimistic, if a bit battle weary. “After numerous attempts to better integrate health and social care over the years,” she says, “there is growing impatience among patients, and the staff who care for them, to provide seamless services which no longer allow patients to fall through the gaps.

“With the right political will, coupled with the commitment of nurses and other members of the health and social care team, it should be possible.”

The BMA’s Scottish chair Brian Keighley is chuffed that it’s ciao to CH(C)Ps (the BMA was calling for that even before the first CHP was set up!), but hopes HSCPs won’t get “bogged down” in bureaucracy. “We are therefore pleased that the Scottish Government has explicitly stated that the role of doctors will be strengthened in these new structures,” he says.

But – as controversy over integration already taking place in Highland only underlines – it’s a rough road ahead, and one which, moreover, is being taken at a time when resources are pretty thin on the ground.

Despite my previous disappointments, however, I’m still rooting for this to work – frankly, with ageing populations, more ill health and less money around, it bloody well has to. My optimistic self even hopes that the current financial and other pressures might prove a spur to successful change, rather than a barrier.

So I’m a bit excited – cautiously excited, but excited nonetheless. I do wish they’d called them something else, though: HSCP sounds more like a bank – and that wouldn’t augur well…

Western Infirmary, Glasgow Picture: Stephen Sweeney

You’ve got to feel a bit sorry for Glasgow’s Western Infirmary. Last week the hospital was in the news for all the wrong reasons as a report of its care of older people had been less than flattering.

Healthcare Improvement Scotland (the body that used to be Quality Improvement Scotland, and before that was the Clinical Standards Board – do keep up) has been charged by the Scottish government to carry out a series of inspections to “provide assurance that older people are being treated with compassion, dignity and respect while they are in an acute hospital”.

The first such inspection – at the Western Infirmary in February – found that, actually, that wasn’t entirely the case. Oh, overall it wasn’t bad news – or, as Susan Brimelow, the chief inspector put it: “Our inspection team noted areas where NHS Greater Glasgow and Clyde is performing well.” For example, staff and patients seemed to get on pretty well – at least I think that’s what she means by saying that “the majority of interactions we observed between staff and patients were positive”, which sounds like the way it should be.

But of course it didn’t stop with the positive – and, naturally enough, my friends in the Scottish media were (rightly) quick to pick up on the negative (as, indeed, I did myself).

Because, on the face of it, the negative was pretty bad. On nutrition, for example, which was a main focus of the inspection, there is definite room for improvement, with the report saying that “not all” nutritional assessments were being carried out on admission or during the patient’s stay, and that personalised plans, to meet individual patient needs, were consequently not in place.

This paints a picture of hospital patients – who are, by their very nature, vulnerable, and for whom decent food could literally mean the difference between life and death – not having their needs properly addressed.

On the plus side, however, reading the whole report it emerges that the forms were filled in for the majority of patients whose notes were inspected, and those taking part in a survey overwhelmingly said that if they needed help with the likes of utensils at meal times, this was given by staff.

You can be sure that if it was me, or someone close to me who wasn’t getting tip-top care, I’d be bloody furious and would probably kick up a hell of a stink. So why do I feel sorry for the Western Infirmary? Simple, it’s because they’re the first.

Over the next weeks and months we will get lots of other reports on older people’s care. Some hospitals might be – probably are, actually – providing much worse care than the Western Infirmary (where feedback from patients showed they enjoyed the food, for example, and found the nursing staff friendly and chatty). But I bet that after the first few, unless they throw up something really startling, they won’t get much media coverage.

Remember the Healthcare Environment Inspectorate? That’s the body set up in 2009 to tackle healthcare associated infections by a programme of announced and unannounced inspections. Its first reports were met with acres of media coverage – hardly surprising, as it did uncover some pretty shocking things.

But last week, just a day after the Western Infirmary report was published, the results of an unannounced inspection of Perth Royal Infirmary were put into the public domain.

As usual, there was a mix of good and bad news: NHS Tayside is “working towards complying with standards to protect patients, staff and visitors from the risk of acquiring an infection”, said the ubiquitous Susan Brimelow. But although the areas inspected were “clean and well maintained”, all was not perfect. NHS Tayside is “required” – that’s the strong term – to ensure that medics fill in documents around a system to reduce infection (actually really quite important that they should) and ensure good communication between estates and ward staff, again pretty important.

Quite possibly there has been some media coverage of this report – I’d hope at least the Perthshire Advertiser would do something – but a fairly extensive Google search (I even looked at the second page!) has failed to find anything at the time of writing.

So what does this show us about the value of inspection reports? Well, it suggests that it’s best not to be the first in line if you want to avoid negative headlines. It also indicates that the impact of reports dwindles with time. In a way, it’s an object lesson in being open and transparent – if you go looking for problems, you’re bound to find them (because nobody is perfect), but if you’re consistent about reporting them then they lose their shock value. Dare I even suggest they get a bit boring?

Some might question the value of such inspection regimes – after all, the most recent reports were fairly positive, with most people getting decent and dignified care. Would money be better spent elsewhere?

On balance, I think inspection has an important role – both as a means of rooting out bad practice and as a spur to keep up standards. It’s also a way that patients and the public – and concerned members of staff – can hold management to account; after all, the more open and transparent the regime, the easier to raise concerns. And even if journalists get bored with an issue, surely that shouldn’t mean their readers do.

That doesn’t necessarily lessen my sympathy for the Western Infirmary. But I suppose someone had to be first.

<em>Picture: Willem van Bergen</em>

Picture: Willem van Bergen

Today the Scottish parliament’s health committee is due to start hearing evidence on the Alcohol (Minimum Pricing) (Scotland) Bill. We’ve been here before, of course, although the last time the health committee discussed the issue, circumstances were very different.

Then, the health secretary Nicola Sturgeon was trying very hard to build a consensus with other political parties so that she could get the measure passed as part of the wider legislation that was to become the Alcohol etc. (Scotland) Act 2010. As we know, this she failed to do.

This time, with a majority in the Scottish parliament, Ms Sturgeon probably doesn’t have to worry about making friends with the other parties. Presumably, however, she would still like to have cross-party backing – if nothing else, to give the likely new law more legitimacy and to make its passage through parliament a bit easier.

So far, that’s not looking too likely. Although the Lib Dems have changed their pre-election position and have withdrawn their opposition, Labour and the Tories remain intransigent.

I, for one, find this more than a little depressing. I really believe that Scotland needs this legislation and I fear that those who oppose it have (often understandable) vested interests, or that they are missing the wider point.

Scotland has an alcohol problem: nobody is denying this, not even those who oppose minimum pricing. The evidence is plentiful and compelling. I’m not going to relist all the frightening statistics about numbers of alcohol-related deaths, A&E visits and illness, nor the social and economic consequences – the devastating effects on communities and families – because I don’t think anyone disputes them. Suffice to say it’s a major, major problem.

Lots has already been done, and is being done, to try to alleviate it – for example, changes in licensing laws and crackdowns on promotions. These are good measures, but they don’t go far enough. We need to do more, and I would argue that minimum pricing would be a step in the right direction.

So why do I think this? Perhaps strangely, it’s not primarily because of the research that’s been done on the effects of pricing. The modelling done at Sheffield and elsewhere, showing that consumption would go down if prices went up, might be perfectly valid – but it’s not, for me, the most compelling reason.

Looking at the personal experiences of other jurisdictions is rather more persuasive. Tonight, the health committee members will sit in an evening session to hear evidence via video conference from Professor Timothy Stockwell of the University of Victoria in British Columbia. Professor Stockwell has become a bit of a poster boy for those in favour of minimum pricing since his visit to Scotland last year. I attended one of the events at which he related the Canadian experience, where a form of minimum pricing has been in place for more than 20 years. Many different forms, as it happens, as each Canadian province applies its own rules.

Of course the circumstances aren’t identical – Canada has a state monopoly on alcohol, and I don’t hear anyone suggesting that for Scotland – but to say we can’t learn from the experience would be narrow-minded, to put it charitably.

From the Canadian example, it would appear that minimum pricing is most effective when it is index-linked and where it is accompanied by other policies such as incentives for low-alcohol products. But the effects of increased prices are clear. In British Columbia, where the government monopoly has set minimum prices for more than two decades, only spirit prices have been updated in line with the cost of living. Here, a 10 per cent increase in minimum price has shown decreases in ethanol consumption ranging from 1.5 per cent for beer to 8.9 per cent for wine, and 3.4 per cent for all drinks.

In Saskatchewan, however, which adjusts minimum prices to take inflation into account, and which prices high-strength alcohol more prohibitively, a 10 per cent increase led to an overall reduction of consumption of 5.2 per cent. In addition, a reduction of taxes on low-alcohol beer, combined with a reduced tax on low (up to 4 per cent) beers, mean that the latter now account for more than a third (37 per cent) of the beer market.

So far, so convincing – to me at least. But still, that’s not my main reason for believing that a legal minimum price is the right thing to do. In my view, it’s vital that the Scottish parliament passes this legislation because it sends out the right message. You can argue all you like that it will benefit only the supermarkets, who will be able to charge more for products, or that it will be difficult to police, or that it won’t actually help the health of all of those who are drinking dangerously or riskily. But the fact is that we need change at a cultural level, and legislation is one of the levers to help accomplish this.

Scotland as a whole needs rehab – and while legislators don’t take the opportunity to send out a clear message that drinking can be dangerous, then they are copping out.

This is why the alcohol industry – much of it at any rate – is against minimum pricing. What they don’t want is a clear governmental message that their product can be harmful – and who can blame them, as that’s how they make their money? And they have a good point in many cases – minimum pricing would have no actual effect on top-of-the-range malts, for example, because they already cost more per unit than even the wildest dreams of the pricing advocates. But the message that sends out – that alcohol can cause harm – could cause sales to take a hit.

What’s more, if Scotland pushes ahead with this, then she certainly won’t be alone. Other parts of the UK are already signalling pretty strongly that they are likely to follow suit, such as Northern Ireland (a fellow nation with an alcohol problem). Look at what happened with the ban on smoking in public places. Once a couple of jurisdictions introduced it, then much of the rest of the world followed like a set of dominoes.

Alcohol is different to smoking, of course – drinking in moderation can even confer health benefits, unlike the evil weed. So it’s understandable that the alcohol industry does not want to be (low) tarred with the same brush.

Our politicians don’t have the same excuse, however. I do them the justice of not assuming that they have opposed and continue to oppose the SNP’s plans simply on party political grounds. Their reasons for opposition might feel perfectly valid and justifiable to them.

But they are missing the bigger picture. As Professor Stockwell said at that meeting in September, the eyes of the world are on Scotland. Scotland has a long tradition of health and public health innovation – here’s hoping our politicians don’t lose sight of that.

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<em>Picture: alexkerhead</em>

Picture: alexkerhead

For a certain group of people – a community, if you will – this time last year was one of anxious anticipation. No, not Christmas, nor even Hogmanay: rather it was 2 January and it was to take place on the radio.

The Archers, the everyday tale of country folk, had been building to a climax. We thought there would be a death, but whose? Would it be Helen, about to give birth for the first time and facing a long, hazardous drive to hospital in the snow? Would it be (praise be!) Linda Snell, exhausted after the efforts of the Christmas show?

The excitement was so great that I, and others, accepted a party invitation for that night only on the proviso that there would be access to a radio.*

As it turned out, it was posh Nigel – husband of irritating Elizabeth – who plunged dramatically, and lengthily, to his death from the roof of Lower Loxley Hall; a lesson to us all (at least to those of us with manor houses) that you can’t be too careful when taking down the Christmas lights.

Nigel’s death may still be creating ripples in Ambridge – widow Elizabeth refuses to speak to her brother David Archer because she blames him for her husband’s demise. (David had taunted Nige about being afraid to go on the roof, then, stupidly, confessed as much to Elizabeth when (a) he must have known she’d go mad and (b) the only witness was deid.) But now it has reached the dizzy heights of medical research.

Yes, bmj.com reports today that the “risk of traumatic death” is far higher in fictional Ambridge than in the (real) rest of England and Wales.

Admittedly this is the Christmas BMJ, which tends to be on the lighter side of academia – other tales out today, incidentally, are that men aged 70 or older can “elude the Grim Reaper” by walking faster, because apparently that gentleman never makes it above three miles per hour, and that male orthopaedic surgeons have a better grip strength than male anaesthetists.

Nevertheless the Archers research is relatively rigorous – it uses big, technical words such as “epidemiological” and “confidence intervals”, so it must be meant to be taken seriously, sort of.

The author, a freelance medical and science writer named Rob Stepney, wanted to investigate whether The Archers was more true to life (and death) than TV soap operas. Previously, research has concluded that characters in EastEnders and Coronation Street have a higher risk of death than bomb disposal experts and racing drivers.

Stepney reviewed deaths, childbirth and episodes of serious illness over a period of two decades, from 1991 to September 2011. In this time there were 15 deaths, nine of male characters and six of female, equating to a mortality rate of 7.8 per thousand of population for men and 5.2 for women. This compares to an average of 8.5 per 1,000 in England and Wales for males and 5.8 for women.

Good news then, as overall death rates in Ambridge are actually lower than in the rest of England and Wales. Perhaps we should all move there.

Unfortunately, however, when it comes to accidental death or suicide, the risk is worryingly high, Stepney says. During the study period there was a road traffic accident, a death when a tractor overturned, a self-inflicted gunshot wound – and, of course, the Nigel death leap.

In scientific terms (yes, really), this translates to over a quarter – 27 per cent – of the total mortality in Ambridge. But in real life, accidents accounted for only 4 per cent of deaths in men in the year 2000, which was the midway point in the study.

Over the same period, there have been 13 children born to the 115 characters in the show, (one in a tepee at Glastonbury) making an annual birth rate of just 5.6 per 1,000, compared to 11.4 in England and Wales. But access to healthcare seems pretty good. Stepney points to the aforementioned Elizabeth, who was born with a heart defect, and who recently had a life-saving implant operation – she was lucky, Stepney says. “Nationally fewer than 100 such implants were carried out in 2009, so she may have had privileged access to expensive devices,” he adds.

He quotes Simon Dover, medical adviser to The Archers in 1989, shortly before the period under review, reporting that the programme’s production team had a particular liking for medical stories. And certainly there have been many over the years – sometimes even carrying out a useful public health function.

Greg Turner’s suicide, for example, illustrates the problem of depression among males in rural areas. Ruth’s breast cancer (although I’m assured by one medical listener that it was unrealistically portrayed) certainly raised awareness of the disease, while Jack Woolley’s descent into dementia has made painful – but compelling – listening. And any dairy maids will have been very careful about following environmental health regulations after the recent outbreak of e.coli from ice-cream tainted by Clarrie Grundy’s coming back to work too soon with a tummy bug.

“Although the confidence intervals around the relevant estimates are wide, The Archers seems to have a higher than expected number of traumatic deaths,” concludes the author. “In this respect it would be similar to soap operas set in urban environments and on television. However, in overall mortality, which in epidemiological terms is the most important outcome, The Archers ploughs its own furrow.”

In comparison to last year’s cliffhanger (roofhanger?), the current storylines are a bit tame. But perhaps they actually have another shocker up their sleeves for this 2 January. I’m still secretly hankering for a tragic accident involving Linda Snell, a llama and smug Tom’s organic sausages. Or how about something involving Brian? He could have an affair with a beautiful young woman; they could have a secret lovechild who will then have to be brought up by Brian’s wife, Jennifer, after the baby’s mother dies. Oh no, they’ve already done that.

* It was a great party, there was access to a radio and our lovely hostess was among those who sneaked away to listen.

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Some nuns – probably not on the pill <em>Picture: pandrcutts</em>

Some nuns – probably not on the pill Picture: pandrcutts

Is the Lancet really trying to wind up the Pope just as he approaches one of his busiest times of the year? The venerable medical journal today publishes a call from respected Australian researchers calling for nuns to be put on the pill.

Not for the purpose of contraception, you understand; rather, the idea is to protect them from the scourges of uterine and ovarian cancer.

The reasoning seems sound: for obvious reasons, nuns tend not to bear children. Women without children (nulliparous) have higher risk of dying from cancers of the breast, ovary or womb than women who produce young. Those who take the contraceptive pill, on the other hand, have reduced overall mortality (from all causes) and are also less likely to die from ovarian and uterine cancer – we’ll leave aside the question of breast cancer for now.

The authors – Dr Kara Britt, of Monash University, Melbourne, and Professor Roger Short of the University of Melbourne – reckon that nuns should therefore be given the pill for health, rather than contraceptive reasons.

Their argument is that studies have shown that overall mortality in women using the contraceptive pill is 12 per cent lower than those who have never used it. The risk of developing ovarian and endometrial cancers falls by 50–60 per cent compared with never-users; this protection lasts 20 years, showing a long-term benefit.

“The Catholic Church condemns all forms of contraception, as outlined by Pope Paul VI in Humane Vitae in 1968,” the authors write. “Although Humane Vitae never mentions nuns, they should be free to use the contraceptive pill to protect against the hazards of nulliparity since the document states that ‘the Church in no way regards as unlawful therapeutic means considered necessary to cure organic diseases, even though they also have a contraceptive effect’.

“If the Catholic Church could make the contraceptive pill freely available to all its nuns, it would reduce the risk of those accursed pests, cancer of the ovary and uterus, and give nuns’ plight the recognition it deserves.”

Now I’m no expert on Catholic doctrine – far from it – and as a person who described herself as “no religion” in the recent census, I am coming at this from a secular perspective; but I see a few problems here. The first is that I’m not sure why nuns are being singled out (unless for maximum Vatican-annoyance impact).

Many women don’t take the pill, many don’t have children and even those who do aren’t necessarily maximising their protection against developing cancer – indeed, as the authors acknowledge, women who have children decrease their risks of these cancers if they have their first child at a young age, bear more children, and breastfeed.

So, if we followed the logic of the authors’ argument, the contraceptive pill should be pressingly offered to any woman who didn’t follow that particular life plan.

Personally I have a problem with that, and it doesn’t have anything to do with religious belief. The pill is a drug, and it’s far from risk-free: (a useful summary of the risks and benefits it confers as regards cancer can be found here). Breast cancer is a particularly problematic area. While an analysis published in 1996 suggested that women who were using, or who had used, the pill were at slightly higher risk of developing breast cancer, the Women’s CARE study, published in 2002, indicated that current or former use of oral contraceptives did not significantly increase the risk. A National Cancer Institute-sponsored piece of work published the following year muddied the waters further, suggesting that risks were higher for those – particularly younger women – who had used the pill within five years prior to diagnosis.

But if the evidence around breast cancer is cloudy, it’s much clearer on deep vein thrombosis. Women taking the pill, particularly the third-generation pills, have a slightly higher risk of developing these blood clots – which can be fatal – although it must be stressed that the risks are still extremely small and certainly wouldn’t – didn’t – stop me taking it.

The authors of the Lancet publication acknowledge this, and suggest that “the possibility of health risks, such as venous thromboembolism, associated with use of the combined pill should not be forgotten, and women’s medical history should always be considered”.

I also have a problem with the idea of mass medication (no, not that kind of mass) as a general rule. There is a huge difference between prescribing a drug – the pill, or anything else – which is therapeutic (ie, it will treat what ails you) and prescribing one which may treat what might ail you – maybe, at some point in the future (if the side-effects don’t get you first). The Catholic Church, as I understand it, wouldn’t have a problem with members of its flock taking the pill for an actual, existing health problem (eg polycystic ovarian syndrome). The only thorny issue would be if a Catholic woman was taking the pill for health reasons, and actually used it as contraception too – and, let’s face it, that’s not likely to be the case with nuns.

No, the idea of doling out the pill as a matter of course to anyone, along with their daily bread – or perhaps even baked into it? – is ethically dodgy, to say the least.

Because where does it stop? Statins have been shown to decrease the risk of heart attacks and strokes; should everyone be given a daily dose? (Yes, I’m aware that they can have awful side-effects too; it’s partly my point.) Last week an Irish psychiatrist suggested putting lithium in the drinking water to prevent suicides. Others advocate folic acid into flour to prevent birth defects (although actually I’m rather in favour of that), while the fluoride-in-water debate continues.

I’m faced with the vision of a convent, nay, a world, where the daily repast is not so much food and drink, but a veritable cornucopia of pharmaceuticals.

Does that seem right?

I can’t agree in the slightest with the Vatican’s views on the use of contraception, be it the pill or anything else – indeed, I think the teachings of Humane Vitae do a great deal of harm, particularly in the developing world.

But on the issue of nuns and the pill? I’m probably with the Pope.

A free abstract of the paper can be found here.

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A sewage-strewn Loch Lomond <em>Picture: WTO/Domestos</em>

A sewage-strewn Loch Lomond Picture: WTO/Domestos

A shocking new image reveals how one Scotland’s most cherished bodies of water would look if we had to endure the same sanitary conditions as 2.6 billion people worldwide.

Released by Domestos to mark the launch of tomorrow’s World Toilet Day (WTD), the picture reveals how poor toilet hygiene would devastate Scotland’s magnificent waters. However, for one-third of the world’s population, images such as this are a reality, as they are forced to live without access to hygienic toilet facilities, which contaminate their water supply.

The World Toilet Organisation (WTO), which organises the annual WTD, is a global non-profit organisation committed to improving toilet and sanitation conditions worldwide and dispelling the taboos surrounding toilet hygiene. To celebrate the importance of toilet hygiene and raise awareness of the horrific outcomes for those who live without basic sanitary facilities, Domestos has created a number of images to show how iconic Scottish landmarks would look in similar conditions.

“As the leading experts in toilet hygiene,” said David Titman, brand manager for Domestos UK, “Domestos is committed to help solve the global sanitation crisis and aims help one billion people take action to improve their health and well being by 2020. In the UK we take clean toilet facilities for granted, yet sadly for 42 per cent of the world’s population unsanitary toilet facilities and lack of hygiene is the cause of life-threatening illnesses that can actually be easily prevented – providing the means to good hygiene is the best preventative medicine.”

The images show the devastating effects that limited or nonexistent sanitary toilet facilities would have on Scottish waters. Areas of outstanding natural beauty such as Loch Lomond, or Windermere in the English Lake District, would be nothing more than sewage dumping grounds without the UK’s efficient sewage systems. However, luckily for Scots, this is not a reality – and unlike the 2.6 billion people globally, we are not forced to bath, wash and cook in these awful conditions.

As part of their ongoing pledge to address the global sanitation issue, Domestos has also announced the worldwide roll-out of the Domestos Toilet Academies, starting with a pilot academy in Vietnam, opening next year. The scheme will help provide sustainable and long-term solutions to toilet hygiene that benefit local societies and help stimulate the local economies.

“We understand that the answer is not simply ‘parachuting’ toilets into people’s lives,” David Titman said, “but providing ongoing support to break down the taboos around personal hygiene in some of the target local communities. Through the launch of Domestos Toilet Academies we hope to radically improve sanitation by educating on the benefits of better sanitation and the importance of cleaner facilities.”

Poor toilet facilities and sanitation contributes to the death of approximately 1.5 billion children under the age of five every year due to easily preventable disease, and is the root cause to over 133 million cases of high-intensity intestinal worm infections.

“Having access to a clean and functioning toilet is something that many people take for granted,” said Jack Sim, founder of the WTO. “In the past few years, progress has been made in Vietnam toward improving sanitation; however there is still a long way to go. By working in partnership with Domestos, we can effectively pool resources and expertise to work towards a shared goal for improved sanitation and create a long-term, focused solution that reaches the people that need it most.”

Domestos Toilet Academies, in association with the WTO, will aim to radically improve sanitation and reduce the spread of disease that currently kills 4,000 children every day due to poor water, sanitation and hygiene, with the aim of reaching 100 billion people by 2020.

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<em>Picture: HujiStat</em>

Picture: HujiStat

If you want to improve your chances of surviving a visit to hospital, best wait until September.

That’s the implicit message from the Royal College of Physicians of Edinburgh (RCPE), which is today warning that patient safety is “compromised” in August when the latest intake of medical trainees comes into post.

The UK’s newest doctors – most of whom were medical students until a few weeks ago – started work on the first Wednesday in August, coinciding with the date when other doctors in training rotate into other positions.

Although there is already research evidence to show that patients admitted at this time have a higher early death rate than at other times, today’s announcement from the RCPE is among the strongest criticisms yet (they call it a “nightmare” in the press release title) of a system which not only ensures that hundreds of doctors are starting a new job on the same day, but that they are doing so at a time when many of their senior colleagues are on holiday.

This might make sense in some ways – for example, if a consultant surgeon is away, then operating lists will have been cancelled – but emergencies do not tend to wait until Professor So-and-So gets back from holiday or until new doctors get up to speed.

To back its criticism of what tends to be known as “Black Wednesday”, the college, along with the Society of Acute Medicine, conducted a survey of doctors’ experiences throughout Scotland and the UK. The findings, published in the journal Clinical Medicine, are clear. More than nine in ten (93 per cent) of respondents believed the August changeover had a negative impact on patient care, 90 per cent thought it had a negative impact on patient safety and 58 per cent thought it had a negative impact on doctors’ training. The negative effects were found to last for up to one month.

Eight in ten of the 763 respondents thought the situation could be greatly improved by moving away from the current national changeover on a single day to a staggered transition by grade, taking place over a period of a month. Those who made comments also supported moving changeover to a different time of year to eliminate conflict with the holiday period.

Dr Louella Vaughan, honorary consultant physician in acute medicine at the Chelsea and Westminster Hospital in London, and lead author of the study, said the survey results added to the emerging evidence base indicating that the current August changeover system increases a number of risks for patients, including an increased early death rate.

“Over 90 per cent of doctors who responded to the survey believe that patient safety is compromised every year in August by this outdated system,” she said. “When considered along with other related evidence it is clear that the current system is in urgent need of reform. The doctors surveyed have indicated that not only is there an appetite for change, but the desire to enthusiastically lead and support it. All that is lacking now is the political will.”

RCPE president Dr Neil Dewhurst said that patient safety and the quality of patient care should not be knowingly compromised. “For many years doctors have been aware of practical problems caused by this annual changeover. Formal evidence in support of our concerns has, however, been limited, but is now increasing and has reached the level where it should not be ignored.

“Other changes to established systems within healthcare have been shown to deliver real improvements for patients and similar consideration must be given to making the changeover in training safer. We would urge the Scottish and UK governments to review this matter as a matter of urgency.”

The authors of the paper want to see stronger and more consistent clinical leadership for junior doctors at the start of training – and say that consultants should not be used to fill rota gaps or to save on locum costs, but should be providing direct support to trainees.

They also say there is evidence in favour of longer periods of “shadowing” – where medical students are prepared for the world of work by effectively functioning as junior doctors, rather than just clerking in patients – ideally where they will later be working. “Despite the General Medical Council making shadowing a requirement of the final year of medical school, only a minority do so in their place of later employment,” they write. “The GMC also recommends that shadowing students should be ‘protected’ from the ‘business’ of being a junior doctor, which the evidence suggests may be counterproductive.”

The British Medical Association gave a neutral response to the college’s survey and press release – and said that health boards and trusts had a responsibility to make sure staff were prepared. Dr Alan Robertson, of the union’s Scottish Junior Doctors Committee, said: ‘It is well recognised that the August change-over can be chaotic for junior doctors and the services where they are working. Having said that, the fixed change-over date in August does give the NHS a clear date for which to plan services and to ensure that sufficient supervision is in place to provide support to those new in the job. However there could be scope for some of the suggestions posed by the RCPE in their report. It is vital that employers provide comprehensive induction for staff.”

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