Wednesday, 22 February 2017

Metal Nurse: Health Tourism, Red Herring.

During the whole Brexit election I got into some heated debates, especially about the National Health Service. For years and years there has been this myth that the UK was being flooded with health tourists, who would take advantage of the free care provided by the NHS. Never mind that one of the founding principles of the NHS is "Free to the point of delivery" and never mind that the whole "Health Tourist" concept is a red herring. This is generally to distract people from real problems that actually affect their lives, like austerity. Because in the last couple of years mortality rate has risen, while NHS and Social Care has been getting less funding.

It should be noted that immigrants use less services within the NHS than their British counterparts. The reason for that is immigrants (like myself) tend to be younger and healthier. Even being admitted to hospital is rarer amongst immigrants.

But let's for a moment pretend that health tourism is a problem. To do that I'll just check out some numbers... Now currently the NHS budget is around £116.4 billion (2015-2016), the best estimate that the Department of Health can come up with regarding the cost of health tourists is somewhere between £110 - £280 million. Now those do sound like big numbers, and they are. But that accounts for 0.0945% - 0.24%. Are we seriously going to worry about those numbers?  Now those are for what DoH call deliberate health tourists, i.e. those who come to the UK specifically to obtain treatment. Should they be charged, sure of course they should be and most are. But on the other side of the coin is how much they bring into the economy whilst they come to the UK for treatment. Health Tourists also bring somewhere around £219 million back into the economy, by paying into hotels, shopping, transport and suchlike. All of those are VAT'd so that gets back into the economy, and those who work in the industries get paid and thus also pay taxes. So swings and roundabouts. These are people who come to the UK for specific treatments as well.

But then what to do with health tourists from the UK? Because according to this rather interesting research published by PLOS entitled "Medical Tourism: A Cost of Benefit to the NHS" they state:
Our analysis of data suggests that the UK is now a net exporter of medical tourists. While incoming medical tourists may be less likely to declare treatment as primary purpose for their visit to the UK than outbound tourists, data over time clearly shows a greater acceleration in outbound over inbound medical tourists. Despite the variations in numbers of patients visiting different hospitals and in the income per patient, the number of medical tourists was comparatively smaller than the percentage of income generated by them (7% of patients generating close to 25% of private income). These figures suggest that non-UK residents travelling to the UK for medical treatment seek high-end specialist expensive procedures, and may generate substantial revenue. Additional numbers of patients for specialist procedures may also help NHS doctors with surgical learning curves.

But let's take a case study on one of these awful health tourists. As mentioned above I got into some heated debates with a lot of racist people regarding the NHS usage by foreigners. Their favourite story was about this Nigerian lady who came to England to give birth to four children and then left with an unpaid bill. The one issue they didn't seem to understand is that Nigeria isn't in Europe, let alone in the EU. But they also either deliberately left out details or never got around to reading the full story because their lizard brains couldn't handle it. This story has since been touted by media outlets like The S*n, Daily Heil and Sky. Talking about the horror of the cost to the common man, even the BBC headline is focused on the financial cost, as opposed to the human cost. For those who need a quick update on the actual story I'll summarise it:

Nigerian woman was pregnant with 4 children. She got told by her doctors that she'd be better off giving birth elsewhere as it would be safer for her. So she decides to go to the US where a large portion of her family lives. She gets there only to find out that her paperwork is wrong. So she has to turn back, with a stop in the UK, where she has no relations. While en-route she was taken ill. As the plane lands she is taken to hospital, where she gives birth prematurely. One child died at birth, the remaining three were taken into Intensive Care. Another child dies shortly after. The patient herself got discharged after 6 weeks. Quite frankly the headlines shouldn't be about the cost, the headlines should read about how well the NHS staff did in saving both mother and children. She didn't want to give birth in the UK. She didn't want two of her babies to die whilst in a land she doesn't know and has no one in.

But then you do have those who come to travel to the UK, because you know people like to travel. And you can't always account for if you get ill during your travels or not. Now this is where it gets a little bit trickier. Because when you are travelling in a different country you don't really expect to have to get any sort of treatment. But normal use is estimated to be around £1.8 billion, still a tiny 1.15% of the total NHS budget. And most of that can be recovered through European Health Insurance Scheme (well for now anyway). Other countries do seem to be better at claiming money back for when British tourists take ill in the EU, then the NHS. But that is more due to administration costs.

Now let's compare those numbers to something that does have real impact on the NHS. According to the latest numbers I can find (from 2012) diabetes and diabetic care costs £13.750 billion. 85% of which Type 2 Diabetes is accounted for. And this is expected to be increased to £39.8 billion by 2035/36. T2DM is largely preventable through healthier living and better lifestyle choices.

Obesity is also largely preventable through healthier living and better lifestyle choices and that costs the NHS an estimated 
£6.8 billion. Within the EU the citizens of United Kingdom have the highest rate of obesity.

Alcohol costs society as a whole £21 billion per year, £3.5 billion of those to the NHS. Again this is through lifestyle choice of those who live in the UK.

Then there's smoking. Which costs the society upwards to £14 billion, with £2.7 billion costing the NHS. Bear in mind that those numbers were calculated in 2010.

In conclusion is it really worth hounding and demonising people coming into the UK for medical treatment when the UK citizens themselves take it for granted and should we not also be as disparaging to the UK citizens who leave the country to seek treatment elsewhere? In my opinion, as a healthcare professional and as an NHS employee, the fact that people actually want to come to the UK to receive their treatment makes me proud. And it should make the citizens of the UK proud because it shows that we are doing something right.

Other sources include:

Full Fact

The Conversation

King's Fund.

Thursday, 16 February 2017

Metal Nurse: Edward Jenner healthcare hero

Me in Hyde Park, with  Edward Jenner
Some time ago I went to London with my beloved to spend the weekend. Whilst there I visited Hyde Park for the first time where I came across this monument of a man who changed the landscape of healthcare indefinitely. For the better. I am of course talking about one of the great pillars of public health, Edward Jenner. The father of vaccinations. You will undoubtedly read many many ‘Alternative Facts’ by anti-vaxxers. But as usual they tend to be more confined within the fiction section of third hand bookshops. They lie about vaccines in general, but some of the lies they repeat over and over again about Edward Jenner are astounding. There is a made up story that his son died after receiving the smallpox vaccine. He died at 21 from tuberculosis, which incidentally we now have a pretty effective vaccine for. They also lie about smallpox, alternating between it being never eradicated, just renamed, or simply never that bad in the first place. Yeah, between 300-500 million people died from it in the 20th century alone (until it was eradicated of course), it had 20-30% mortality rate, couldn't have been too bad a disease.

Smallpox had been a scourge on mankind throughout written history. Ancient writings about it were found in a medical book from India, dating from as early as 1500 BC. King Ramses V had been infected by it, cases found in China dating at least 1100 BC. It made no distinction between classes, it knew no boundaries, afflicting the poor and rich alike. Those who were "lucky" enough to survive would be left with permanent scarring. It is a virus mostly transmitted via close contact and droplets coughed by the infected individual. The virus could even be spread via infected cloths, incidentally how the British conquered the Americas when General Jeffrey Amherst gave Native Americans blankets carrying the smallpox virus, quickly decimating the previously unexposed population. The afflicted remained contagious until the last scab healed. There was no treatment available. The only way it could be controlled was with vaccination. And thanks to extensive immunisation programmes the last known wild case of smallpox was in Somalia, in 1977. But it is known that there are vials of smallpox left in both the US and in Russia.

Chinese Variolation
In itself the idea of immunisations wasn't anything new, an immunising technique called variolation had been practised in China and Turkey and some parts of Africa since at least 1000 BC. That form of immunization was introduced to England by the 1700's. It wasn't a particularly safe practice, though safer than getting the disease itself. It involved drying the scabs of previously infected individuals and blowing them up people noses. (Which admittedly is awfully similar to the flu nasal mist spray we use today.) In Sudan and Turkey this practice consisted of collecting fluids from the smallpox postules and rubbing the pus into a cut on the person receiving it. Uptake of either practice in Europe was lacking because the medical establishment had dismissed the practices as witchcraft or folklore. It wasn't until the 1700's that an Italian doctor by the name of Emmanuel Timoni witnessed the practice in Constantinople and then wrote about it and got it published in Philosophical Transaction in 1714, that it received some attention from the higher classes of Europe. Mostly thanks to Lady Montagu who had been permanently scarred by smallpox herself and lost her brother to the same illness.

Edward Jenner was a doctor hailing from England. Jenner himself had been inoculated when he was 8 years old via the practice of variolation. During his medical apprenticeship he took a keen interest in cowpox and how it might possibly lead to protection against smallpox, something that had been taken note of before, specifically by another English physician John Fewster, a friend of Jenner's, and a farmer named Benjamin Jesty. They had observed and reported that milkmaids infected with cowpox were invariably immune to smallpox, this essentially started the mass immunization programs. In essence he didn't discover vaccinations, he popularised it.

Jenner first experimented on eight year old James Phipps, injecting a small amount of cowpox into his arm. After James had recovered from the inoculation Jenner attempted to infect him with smallpox. Neither James nor the children who shared his bed developed smallpox, thus discovering herd immunity. His theories were revolutionary for the time and a lot of people refused to believe them. With the advent of vaccinations came the Anti-Vaccine Movement. Because the idea was so mind blowing even the establishment initially refused to believe it, leading Edward Jenner to do further experiments with more children, including his own child.

By today's standards these were extremely unethical experiments. But thanks to these experiments Jenner managed to convince the establishment of the effectiveness of his method, replacing the more dangerous variolation. Jenner was reportedly an extremely generous man, when James Phipps had married later in life and had children of his own, Jenner gave him a free lease on a house. He refused to use the discovery to make himself rich. Instead he'd devote his time to vaccinating as many people as possible, even negotiating to vaccinate French soldiers in exchange for British Prisoners of War. By 1840 variolation was confined to the past and Jenner's form of immunisation had taken over.

In addition to his research on vaccinations he also made some great headway into research on Angina Pectoris.

Without Edward Jenner there is a very good chance that we would still be dealing with mass epidemics of deadly, dangerous and disfiguring illnesses like smallpox, measles and polio. I believe Jenner's research into vaccinations was as important as John Snow's sanitation investigation, Joseph Lister’s insistence on equipment sterilisation, Ignaz Semmelweis preoccupation with the importance of hospital staffs hand-washing and Alexander Fleming's discovery of penicillin.

Vaccines save lives.

Edward Jenner was a hero. Even Napoleon accepted that.

History Of Vaccines

BBC: History, Edward Jenner.

History of Immunology by Arthur Silverstein

Edward Jenner and the History of Smallpox and Vaccination, by Stefan Riedel.

Monday, 6 February 2017

Metal Nurse: Loss of Liverpool Care Pathway

I've tried not to be too political on this blog, for mostly professional reasons. It has happened at least once. But seeing as this is my blog I thought that this one time (and possibly more often after) I can be. Because this is one topic that really riles me and gets me going. The loss of the Liverpool Care Pathway. I have written previously about how Dying Matters, it is a fundamental part of all good nursing. How we treat the dying patient. How we help the bereaved family. Because how you die stays in people's memory.

For those who don't know. The Liverpool Care Pathway was set up in the late 90's in Liverpool. The aim of it was to provide the best possible care for those who were dying. It provided a framework on how to assess the patients condition, when to continue treatment, when to discontinue treatment and when to provide palliative care. To provide a review of whether further tests and examinations were needed, if artificial hydration should be started when the patient refused diet and/or fluid intake. In other words when to provide comfort care for those in their last hours of living, to provide them with a pain-free, and most importantly, a dignified death. It was a way to provide hospice care in a hospital.

Since 2014 we have not been able to use it. It was completely phased out with the order that each Trust should develop their own pathway, funny considering that the report that the DoH published a document called "More Care, less pathway.". This the Daily Hatreds concluded was victory for the public. Even though the review stated that that LCP was model of good practice, but because of individual mistakes it had to be discontinued. The pathway was excellent, and continually updated. But as usual human beings are fallible. Talking about death and dying is not easy, especially when the family are hellbent on that their relative should live forever. Some people had complained that it was a tick box exercise, which as usual misses the point of these documents. They are there to assist doctors and nurses in providing good care, making sure that all the best care was provided. But as with all good pathways the LCP was proactive, as the patients condition changed for better or for worse, their care and treatment would be re-evaluated. No one stayed on the LCP indefinitely, if someone made a recovery, which does happen because the human body is an amazing thing, then those patients would be re-examined, re-evaluated and and treated accordingly. It was never a "one-size-fits-all". It was a dynamic pathway like all good care pathways are.

All thanks to rags of hate like Daily Mail, Daily Telegraph and Daily Express (The triumvirate of Gentleman's Hate). These papers started reporting that there was a widespread misuse of the LCP, that healthcare professionals were using it as a means of euthanasia, and so on and so forth. The Daily Hate was especially gleeful in publishing false news about doctors withdrawing hydration of neonatal patients.  For a whole year Daily Nazi went on and on about the LCP, stating that families weren't consulted, that patients were put on it without their consent. That patients were put on it to speed up their death. For a whole year the Daily Triumvirate of Gentleman's Hatred continually on a near daily basis misinterpreted proper healthcare decisions, using their misguided (broken) moral compass on how doctors and nurses should do their work and how they should come to their decisions. Contrary to popular belief, the LCP was never misused, just grossly misunderstood.

Quite frankly the only truth was poor communication on the professionals part, which is not unusual. Talking about dying in hospital is often very hard, not just for relatives. But also for those professionals, because you don't want to be seen like you are failing in your job by letting someone die. Good communication is of course key to all good care. This comes with experience and training. It does not come from reading the Daily Triumvirate of Gentleman's Hatred. But the fallout has been such that some relatives seem to think that DNACPR and Advanced Directive are somehow Liverpool Care Pathway remade and should not be considered at all. But since scrapping the LCP we have got better at talking to relatives and patients regarding end of life care has improved, but the availability of said services have not. I know there was much rejoicing when it was scrapped, but when NICE published new guidelines on end of life care. It was all very much a rehash of the LCP, it just can't be called that now. We provided individual care to all patients before and we still do so.

And the fallout didn't just affect adult nursing, it also affected paediatric nursing. Paediatric Nursing had been trying to develop a similar pathway for years. Seeing as there was the need for one. Palliative care for children is not as well known, generally again this is not a subject that a lot of professionals want to have. They will, but no parent actually wants to hear that there is nothing that the hospital can do for their child and that they would benefit from palliative care, rather than active treatment. The need for a tool for healthcare  professionals to use in order to assist them with making those decisions and the rationale for those decisions was lacking. It's a conversation that neither party wants to have, but both desperately need.

Sometimes further treatment is just inflicting pain on children, with no hope of either cure or reprieve. Extending hope when there is none. Children, like adults, need and deserved tender loving care. And like with adults, how children die stays in the memory of those who live on. But again, thanks to the triumvirate of gentlemans's hatred, the development of said pathway for England(and Wales) was halted almost indefinitely. NICE since have published up guidelines on how manage and plan end of life care for children. Scotland have also been developing an excellent one.

As healthcare professionals we really could do without all the blame and suspicion that is cast on us by paper of Gentlaman's Hatred. It gets in the way of good care when patients and relatives judge our actions based on lies and falsehoods that are propagated by those papers. The readers and writers of said newspapers looked at the loss of the LCP as some sort of victory for the common people, when it was anything but. It was the common people who lost out on a very effective, very good tool that was made for them. It's the common people that lost out. No one goes into healthcare with the thought of making money, they go into it for fulfilment of the job. But it's hard to do the job when writers who don't know anything about healthcare cast doubt and aspersions about your reasoning for being a nurse or a doctor. My job is hard enough as it is, please stop making it harder. I want to care for my patients, not for rumours.

Wednesday, 1 February 2017

Metal Nurse: Physical health within mental health

One of the many healthcare areas that hold great interest to me is mental health. Prior to starting my nurse training I had worked in secure services mental health for 6 years. It was an eye opener. It was essentially what lead me to doing my general health training as opposed to mental health training. This article should tie with my previous article on self harm. The focus here is of course on how patients physical health should also be the focus within a mental health setting. What was often not always noted is that physical health problems can manifest as mental health issues. For example infections can and do lead to delirium, especially Urinary Tract Infections. Even constipation will cause confusion and mood swings.

Quitting Smoking
My main interest at the time though was the physical well being for those patients. The lack of physical health care for patients in long term mental health institutes has been recognised for a long time. Patients with schizophrenia are for example known to die from natural causes sooner than the general public. Hence the need for mental health nurses to be trained better in order to recognise and tackle physical health issues. The most common causes for the mortality rates are smoking and obesity.

The rates of smoking are two to three times more common within patients who have schizophrenia than the general public, two out of every five cigarettes are smoked by people who suffer from mental health problems. And people who have bipolar disorder have also been known to be 2 to 3 times more likely to smoke. Not only that but those with mental health problems smoke more than the general public that smoke. So the dangers of smoking are enhanced and the importance of smoking cessation becomes even more important.  The dangers of smoking cannot be over stressed, and the benefits of quitting smoking cannot be underlined often enough. According to a systematic review by the BMJ, quitting smoking has not only physical health benefits but also mental health benefits. And that's across the board. Or as the meta-analysis says itself: 
"Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers.  
There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders. " 
Essentially. Anxiety went down, depression went down and stress all significantly decreased AFTER quitting smoking. Which all in all just says to me that mental health care facilities should place a stronger focus on smoking cessation then they already do. What should also be added is that if you are on medication for your psychiatric issues, you take less medication if you quit smoking. The reason being is that smoking increases the body's metabolism of most of those drugs. This is especially apparent in those who take clozapine. For example when the smoking ban came into effect within UK's mental health facilities the plasma serum levels went up, because of patients reduced smoking. But that often wasn't accounted for when considering the patients medication dosages.

Quitting smoking isn't easy, I know that from personal experience, and in I would imagine that those who already have diagnosed mental health problems will find it more difficult hence the need for more robust support during the smoking cessation. Which also just brings the point that nurses should also work as role models in terms of their health promotion. Seeing as there are so many nurses that still smoke. It is pretty difficult to provide good support if you aren't willing to seek out support for it yourself. We also have to smash the preconception that drinking coffee and smoking cigarette first thing in the morning is something that is okay, and think that it is a safe and effective way of getting someone to calm down when they are having a psychological breakdown. Verbal de-escalation works a lot better then the offer of a cigarette and a cup of coffee.
Learn How To Become...
As mention previously obesity is the other big(no pun intended) issue for mental health patients. It is well known that certain psychiatric medication induce weight gain and in longer term morbid obesity. Obesity leads to several physical health related issues as well as mental health. This would include,  Type 2 Diabetes Mellitus, Stroke, Coronary Heart Diseases, Infertility, Loss of Bladder Control, and many many more.

Regarding T2DM, it becomes a big issue within a hospital setting as often the health care staff looking after patients with diabetes sometimes mistake hypoglycaemic episodes with delirium or psychological breakdown, hence delay of proper treatment. With patients who suffer from schizophrenia they also often suffer from defective glucose tolerance and insulin resistance. Which makes recognising diabetic crisis hard to tell from psychological crisis, for those who are not appropriately trained.

Then there the psychological issues. Being obese can lead to depression, anxiety, body dysmorphia, low self esteem, and many more. Of course if you already do have those issues being obese will exacerbate those issues.

Since weight gain is a very common side effect of psychiatric medication, and well known by mental health care professionals,  I do wonder why rolling out weight management plans alongside starting the drugs isn't done. Because losing weight is not an impossibility like a lot of professionals seem to believe.

 The medications will increase their appetite, but that is not the only reason for it. Whilst in a secure setting patients become more idle, and their diet intake tends to be very poor. I remember watching patients eating increbile amounts of takeaway foods, sweets and gulped vast quantities of soft drinks. But on the flip side I don't remember an awful lot of healthy food stuff being promoted, like the 5 a day fruit and veg intake.Or just the whole Change4Life campaign. Or drink to water. Or even Meat Free Monday's.

In a large study published by NJEM, it was shown that with the right plan and the right intervention, patients with serious mental health problems could lose weight and not just that but keep their weight down following lessening of weight loss sessions. Even with obstructions like hospital attendence's, breakdown in mental health and so forth. Of course like with smoking, it is sometimes hard for nurses to be role models for life style changes when they also feel like they can't tackle the subject due to their own life style.

All in all, what I personally would like to see more of is further physical health training for mental health nurses, and of course vice versa for general nurses. Because all training for either will only improve both professionals healthcare practice.