Category Archives: Clinical conditions

Nick Bostock reports at GPonline that:

Under-pressure GPs are delivering ‘remarkable outcomes’ on cancer

You can read the complete article here. Nick reports:

GPs ‘can take a lot of credit’ for marked improvements in early cancer diagnosis and reductions in the proportion of cases detected as an emergency, according to a cancer expert.

In the year to March 2018, the proportion of cancer patients who first presented at hospital as an emergency fell to 18.8% – down from 21% in the year to December 2012.

Over roughly the same period, cancers detected at an early stage increased significantly – rising from 46% in 2013 to 52% by mid-2017, according to figures from the National Cancer Intelligence Network (NCIN).

However: GPonline reported earlier this year on research showing that GPs were as good as consultants at making appropriate use of cancer diagnostic tests – and yet pledges to give GPs direct access to four key diagnostic tests – blood tests, chest X-ray, ultrasound and endoscopy – have not been delivered in many areas.

Isn’t it about time that GPs were also given access to the new technology for GP consultations via mobile and Skype? This is currently being ‘rolled out’ by GP at Hand. Here’s a transcript of the R4 Today programme 13 September at 6 mins to 9:00 am (I made this transcript and I believe it’s a fairly accurate job – but any mistakes are mine):

(Int) Interviewer

AP (Ali Parsa, CEO Babylon – parent company that runs GP at Hand)

RV (Dr Richard Vautrey, Chair GP Committee, British Medical Association)

SoS = Secretary of State

 

(Int): So Ali Parsa just explain to us how your App works.

(AP): So, we have a very simple service. So, what it does is allow patients to check their symptoms whenever they want. To make an appointment with a doctor within seconds, to be able to see a doctor within minutes. In fact, I was just checking my App and it says that if I want to see a doctor I can see one at 9 o’clock today, in the next few minutes.

(Int): You mean ‘see’ over the phone?

(AP): Over the phone. And if you want to see somebody physically then, you can go see them that very same day. It is open 24hrs a day, 365 days of the year. And it is available for the same price the National Health Service pays any other GP. What we have done is to solve the problem of accessibility and the continuity of healthcare – using technology and what the SoS and the NHS is doing today is celebrating that and promising it for the whole country.

(Int): And Richard Vautrey, this is something which patients complain about again and again, isn’t it, access to their GP, so is this kind of App the solution?

(RV): We have real concerns, as well as patients do, about the inability of many practices to be able to offer enough appointments and that’s simply because we haven’t had the funding over the last decade to support the expansion of the health service to be able to meet the growing needs of our patients. What General Practices are doing right now is seeing thousands and thousands – if not a million – patients today offering, you know, face-to-face consultations and seeing them in their surgeries, so that’s when patients approach them today. So that’s happening right now. What we haven’t got is the resources to be able to offer some of the IT technologies in every single practice. And the SoS’s commitment to IT is welcome, but we need to see that commitment translated into resources provided to enable every practice to offer this type of consultation.

(Int): But could this kind of technological approach actually help some of the pressure on GPs because people would consult a doctor over the phone rather than going to the surgery.

(AP): Well many practices, if not most practices, already offer telephone consultations. What they haven’t got is the IT kit to be able to offer smart phone consultations, or Skype-phone computer consultations, any many would like to be able to do that, if the technology was provided to them. But the other big difference is that every Practice that is open today will see any and every patient who lives within their area, and we have concerns about the model of which GP Hand has been built, which is primarily about looking at some of the relatively mobile healthy patients and not accepting every single patient who lives within their area.

(AP): I’m afraid Richard that is simply factually not true. We will ask when patients started the service, to ask patients to seek advice if they want to change their GP Practice to our Practice, if they have any clinical issues. Most patients seek advice and join us – we look after them, young, old, sick, healthy, our patients are across the border, and we don’t do that just in Britain, remember we look after one third of the population in Rwanda, and we do so in the United States, we do this in Canada. . .

(Int): But specifically, on this idea of whether you cherry pick patients, it’s likely that patients who don’t have very serious health problems, and maybe younger, are more likely to want to use an App on their mobile.

(AP) . . . but, why is that? If the patient is not very mobile, if the patient is very old, if the patient can’t wait a few weeks to see their GP, they’re significantly more likely to use a service that is continuously available. Many of our patients have mental health issues – they can’t wait for a few days or a few weeks to see their GP. That’s why they switch to us. A thousand patients today will choose to apply to GP at Hand, and then switch their GP Practice – one every three minutes.

(Int): Richard Vautrey, some GP Practices are worried about the fact that if their patients sign up to GP at Hand they then lose that funding, don’t they?

(RV): That’s exactly right. And the way that General Practice is funded at the moment is a balanced mechanism, so those patients who use the service less, and there are many patients that use the service more, and that overall, that compensates one for another. What we have concerns about is that this would effectively replace a personal service with an anonymous call centre and patients don’t want that.

(Int): And finally, Ali Parsa, this was something that commissioning groups in Birmingham were worried about and that was clinical safety – isn’t it better to see a doctor the next day.

(AP): No, it wasn’t clinical safety, you do see a doctor, not a call centre, face-to-face on your mobile and then see one in one of our surgeries. We will open up across the country physical surgeries, their issue was not that. It was an IT hitch that doesn’t allow its screening to be done with your local hospital and that IT hitch has been fixed. This is the future, and I encourage more and more patients to join it.

(Int): Okay thank you both, we’ll leave it there, let us know what your think via twitter.

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Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’

 

Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.

 

Reduction in prevention, cytology and mental health services

Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.

 

STI screening and HIV testing

More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.

 

PrEP availability and reproductive health

The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.

 

Impact of separation of HIV and GUM on staff and services

Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.

 

Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”

ENDS

Editor’s notes:

  1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
  2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
  3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or simon.whalley@mandfhealth.com or Jo Josh, BHIVA, on 07787 530 922 or jo@commsbiz.com.

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On 15 April 2018 Doctors of the World (DOTW) and the National AIDS Trust (NAT) issued a joint statement that called on NHS Digital to immediately stop sharing patient details with Home Office immigration authorities.

DOTW and NAT believe that sharing confidential patient information with the Home Office will deter vulnerable migrant groups from seeking antenatal care or urgent care for infectious diseases.

Here is the DOTW statement:

MPs repeat demand for an end to NHS Digital sharing patient data

The House of Commons Health & Social Care Committee has, for a second time, called on NHS Digital to immediately stop sharing patient details with the immigration authorities. Expressing deep concern about the Government’s approach to sharing confidential patient information, a report released by the Committee on 15 April stated: ‘we believe that patients’ addresses, collected for the purposes of health and social care, should continue to be regarded as confidential.’

The report also states the Committee’s lack of confidence in the leadership of NHS Digital, citing the failure of NHS Digital to act independently of Government and its disregard for the underlying ethical implications of this data-sharing.

Currently, the Home Office receives information about patients from NHS Digital, the body charged with safeguarding patient data. The data is used to trace migrants, which creates a climate of fear where vulnerable people – including pregnant women and those who have been trafficked – are too afraid to access healthcare.

DOTW (Doctors of the World) UK and NAT (National AIDS Trust) have been campaigning for an end to this practice since it came to light in 2014. Both charities gave evidence in the Health & Social Care Committee’s initial hearing on the issue.

Lucy Jones, Director of Programmes at DOTW, said: “In our clinic, day in day out, we see the incredibly harmful impact the data-sharing deal has on our patients. It has reached a point where people do not want to give the NHS their contact information out of pure fear. While confidentiality is in such a precarious state, mothers are not accessing the antenatal care they need, public health is put at risk, and we fear this is only going to get worse”.

“Doctors of the World UK stand with the Health Select and Social Care Committee in opposing this dangerous information-sharing deal between NHS Digital and the Home Office, and are thrilled the Committee has taken such a strong stance. This view is also shared by the British Medical Association[1] and the Royal College of GPs[2]. As a healthcare charity, we believe in the right to healthcare for all. Yet this immoral deal works to scare some of the most vulnerable people in society from seeing a doctor.”

Deborah Gold, Chief Executive of NAT said: “It is scandalous that our data is being shared and our privacy corroded with less and less justification. As an HIV charity, we understand the importance of treating infectious conditions and limiting the spread of epidemics. When people can’t trust the NHS with their data, that good work is undone and we face a public health risk. There is nothing to be said for this practice, which deters people from accessing healthcare.

“Data sharing should have been stopped when the Health & Social Care Committee first called for it, and it certainly should stop now they have, for a second time, demanded an end to this short-sighted and unethical practice.”

Sign our #StopSharing petition to support our NHS Doctors and tell NHS Digital they are NOT Border Guards:

https://www.doctorsoftheworld.org.uk/stopsharing-campaign

[1]https://www.bma.org.uk/news/2018/january/patient-information-shared-with-immigration-officials

[2]http://www.rcgp.org.uk/-/media/Files/News/2018/RCGP-letter-to-NHS-digital-from-chair-march-2018.ashx?la=en

The Commons Health Select Committee says:

Dr Sarah Wollaston MP (Chair): NHS Digital are an organisation that the public need to have absolute confidence will respect and understand the ethical principles behind data-sharing [and they] have not shown us at all that this is part of what [they] are considering’.

Dr Paul Williams, MP for Stockton South and a practicing GP, questioned “what advice would you give to clinicians about what they should inform their patients so that this information is classed “with consent”?’

Luciana Berger, the MP for Liverpool, Wavertree urged NHS Digital to reconsider, calling the deal ‘a matter of life and death’ for an extremely marginalised and vulnerable patient group. 

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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A new study examining breast cancer awareness in India has found that a lack of early diagnosis is leading the country towards an epidemic.

The research, which is the first of its kind to look at breast cancer awareness in India, found that cultural and religious issues mean that women don’t access health services, are reluctant to consult male doctors, neglect their own health due to family obligations and are over-dependent on other family members to seek medical help, all of which causes delay in diagnosis.

The study found that traditional marketing campaigns don’t work for raising awareness of the disease and that community nurses are the most effective channel. A a greater understanding by men is also key to tackling early diagnosis. The study is published this week in the Journal of Business Research.

The research highlights the significance of the country’s rapid economic development, leading to greater urbanisation, which is leading some women towards a western lifestyle resulting in a rise of breast cancer rates. It describes the issue as one of the biggest health threats facing India today.

Judith Fletcher-Brown, from the University of Portsmouth, visited the country to explore the unique social, economic, cultural and institutional challenges in this emerging economy. She learned that in India’s cities and urban areas, breast cancer is the most commonly diagnosed type of cancer among women. 70,218 Indian women died of breast cancer in 2012 and deaths from the disease are predicted to increase to 76,000 in 2020 with an average age of incidence shifting to 30 years from 50 years. Yet women seek medical care extremely late due to lack of awareness about self-examination and cultural barriers.

Judith interviewed several women by email about their experiences in order to elicit the most open answers to her questions. One participant said that even among friends they are too shy, although there is more openness between mothers and daughters.

Judith said: “India is still a patriarchal society and while women are now in responsible jobs and earning for their families, it’s the men who are still the head of the household. Even educated professional women do not discuss private matters about their bodies with their husbands, fathers or brothers so it’s essential to direct health messages towards men to increase their awareness of and willingness to discuss the problem. Their understanding is pivotal in enabling female family members to access medical help at the earliest stage.”

She also ran focus groups with experts from various breast cancer medical practitioners.
“They told us that in India the subject is taboo and rarely discussed within the family, between men and women or even between husband and wife.”

She found that community health nurses had the greatest impact in raising awareness of early breast cancer symptoms with both men and women. These Accredited Social Health Activists (ASHAs) are embedded in the community and are far more effective than national advertising campaigns in overcoming cultural barriers because they have the trust of husbands and fathers as well as the women at risk.

The study showed that schools are the second best channel through which to raise awareness in young women, and in third place was the media, which has seen some success in raising awareness through charity initiatives in the country. Traditional marketing campaigns were one of the least effective channels.

Judith, from the Department of Marketing and Sales, highlighted the Westernisation of Indian women as a key issue caused by the country’s burgeoning economy: “Women are having fewer children later in life and breast feeding them less which increases their chance of developing the disease. Working women in urban India often have a more western diet leading to obesity which also increases the risk alongside a lack of infrastructure for early diagnosis.

“The emerging economy of India has presented women with new found economic independence and career opportunities but the lack of breast cancer awareness campaigns puts even these educated women at risk.”

The Indian government recognises the problem and has invested money in marketing campaigns via non-governmental organisations (NGOs). But the research indicated that such campaigns are not reaching the target audience.

India’s crisis especially manifests in the thriving cities of Mumbai, Delhi, Bengaluru, Bhopal, Kolkata, Chennai and Ahmedabad, where employment opportunities for women are increasing. A recent report identified the significance of employing more women in India could add $2.9 trillion to India’s annual GDP by 2025. A healthy female Indian workforce is crucial if the country is to benefit from its demographic advantage and sustain its thriving economy.

Professor Vijay Pereira, second author on the paper, said that the magnitude of the problem is enormous and has major policy implications for the Indian government, who he is urging to tackle the problem with better targeted campaigns:

He said: “Our findings reveal complex challenges at national, state and community levels. What is clear is that the state healthcare sector must transform itself to deliver quality breast cancer healthcare and awareness underpinned by effective use of social marketing campaigns. This research presents several proposals that would assist health marketers working in India’s emerging economy.”

The paper is published in the Journal of Business Research, entitled: Health marketing in an emerging market: The critical role of signalling theory in breast cancer awareness. The authors are Judith Fletcher-Brown from the University of Portsmouth and Professor Vijay Pereira and Dr Munyar Nyadzayo from the University of Wollongong in Dubai.

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One of the prime concerns in almost every household is altered blood pressure. Every person craves for a sheer normality in blood pressure, but it is not always the case. As they age, more and more alterations and complications in the blood pressure levels emerges. It can go down resulting in low blood pressure or can also go up to a high level. Although there are no medications prescribed for treating low blood pressure, there are prescribed medicines for treating high blood pressure.

The effects of changes in blood pressure are rapid; sudden changes results in initial conditions like dizziness, nausea, lack of energy to extreme cases like heart attacks. Therefore it is extremely important to keep a constant and strict vigilance on the levels of blood pressure all the time. Gone are the days when you have to rush to the doctor every time you need to check your blood pressure levels. Now you can directly monitor these levels by technologically enhanced equipment from home. These blood pressure monitors are highly efficient and accurate in measuring and depicting the current health status of the body. To choose the best blood pressure monitor for you, you need to consider the following points:

Ensure that your monitor is working properly

One of the most important parts of the entire blood pressure monitor system is the monitor itself. You should look into the validation documents concerning the working of the monitor. It should have the ‘clinically validated’ status granted by the concerned authorities of the country. Such a badge will ensure that the machine has gone through a series of tests and validation procedures and have passed and gained trust from doctors all around the world.

Check whether you have the right cuff size

Another important aspect of every blood pressure monitor system is the cuff that is adjusted around your upper arm. You should ensure that the cuff fits properly onto your arm. If the cuff does not fit properly, it will give faulty readings. The cuff should be adjustable for all arm sizes. You should measure the diameter of your arm and then look into the details of the product to ensure that the cuff fits onto your arm.

The concern over budget

One of the important concerns regarding the purchase of any product is the price of it. Blood pressure monitors also vary in price depending on the features and the validation procedures. You can opt for such extra features like the built-in memory. However, you can cut down on the expenditure by only restricting yourself to the basic needs and features.

Proper calibration of the monitor

An important consideration for any medical device is its calibration. You need to check whether your blood pressure monitor is calibrated or not. Moreover, you need to get it calibrated at least for once in every two years. Look into the procedure of calibration and how easily you can go about it.

These are some of the important considerations that you have to take while choosing the best blood pressure monitor for you. following this set of advice will certainly land you with the best monitor system to check your blood pressure efficiently.

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Traumatic brain injuries, as the name clearly points out, are caused by a trauma to the brain. This often presents itself in the form of an external force, applied with violence at the level of the brain. Despite being protected by the sturdy cranial cavity, the brain can be easily damaged in such cases, its overall functioning being affected. Depending on the type of trauma, the injury can be closed or it can penetrate the cranial cavity. The symptoms of such traumatic injuries depend on the area of the brain that has been affected; the type of injury will also dictate the chosen course of treatment.

Brain injuries

Symptoms

The symptoms of traumatic brain injuries, as it has already been mentioned above, depend on the actual type of injury and the damaged area of the brain. Many people deal with brain injury and memory loss, especially after violent accidents. However, it is important to understand that the cognitive functioning can be affected as well; one can exhibit a wide range of other symptoms, related to the emotional, social and behavioral functions of the brain. The more severe the injury to the brain was the more diverse and intense the consequent symptoms are going to be.

Right after the actual trauma, one can lose consciousness or experience life-threatening symptoms, such as lethargy, inability to move or speak. One can experience moderate to intense headaches, blurred vision and inadequate coordination. Nausea and vomiting are frequent, as well as loss of balance, dizziness and tinnitus. If the cognitive functioning has been affected, one will have difficulties responding, speaking or concentrating.

The speech can be affected as well, with patients exhibiting slurred speech, aphasia or dysarthria. They may lose their ability to move and coordinate, especially when balance problems are associated (damage to the cerebellum). Patients who have suffered from traumatic brain injuries may exhibit personality changes, not to mention experience confusion, social behavioral problems and constant agitation.

If the intracranial pressure reaches high levels, life-threatening symptoms can appear. The patient can lose consciousness, experience an abnormally low heart rate or enter in a state of respiratory depression. In such situations, emergency intervention is necessary, in order to prevent sudden death.

Causes

The brain is protected by the tough cranial cavity and it does not become easily damaged. However, in case of trauma, things change. A violent force can cause a lot of damage to the brain, especially in case of vehicle accidents. Traumatic brain injuries are also common in those who engage in contact sports or those who have been involved in work-related accidents (constructions in particular).

Regular sports can lead to traumatic brain injuries as well, especially when violent force is involved. Other recreational activities are responsible for such health problems, especially in children. They are more fragile, as their bones are still developing and, thus, more vulnerable to such injuries. Traffic accidents, involving any kind of motor vehicle, are often responsible for traumatic brain injuries, including in the pediatric population.

Physical violence is one of the most common causes of traumatic brain injuries, not only in children but also in adults. Child abuse and domestic violence are two main causes of such injuries, leading to life-threatening complications and even death. Industrial accidents, such as the ones that occur on oil platforms, as a result of explosions or due to chemical products, are responsible for traumatic brain injuries (more commonly in men). Traumatic brain injuries are often encountered in war zones, being often caused by explosive projectiles, gun attacks and open-fire combat.

Treatment

In all traumatic brain injuries, emergency treatment is essential, in order to prevent life-threatening complications and death. Depending on the severity of the injury, the patient might need intubation (respiratory support). Emergency surgical interventions are performed, in order to reduce the intracranial pressure and avoid the excess swelling of the brain. Surgery is also recommended in case of brain hemorrhages, for the prevention of further complications.

Before administering any kind of treatment, the patient will undergo imaging investigations. This will determine what part of the brain has been affected and also guide the further treatment measures. The patient will receive analgesics or sedatives, in order to relieve the pain. Hypertonic saline solutions are administered to reduce the swelling at the level of the brain and also the electrolyte imbalances that might cause heart failure.

Fluids are administered intravenously, in order to maintain the blood pressure at a stable level. Medication, such as benzodiazepines, is administered in order to protect the brain against seizures and further damage. Craniotomy might be performed in case of excessive brain swelling or to reduce the intracranial pressure.

Once the acute phase has passed, the treatment will be concentrated on the rehabilitation of the patient. Physiotherapy is essential in the chronic phase, as it can improve the functional outcome and guarantee the best possible recovery from the trauma. Patients can also benefit from speech and language therapy, especially if they have suffered injuries to the parts of the brain responsible for speech. Other treatments include occupational therapy, psychological counseling and NeuroGum supplement.

It is important to understand that the recovery from a traumatic brain injury can spread over several years. In some cases, the recovery is not possible and the patient has to learn how to live with the remaining functioning potential. The support of family and other caregivers is essential for these patients.

Conclusion

Traumatic brain injuries can lead to permanent disabilities, affecting a person’s overall quality of life. The faster one receives treatment in the acute phase, the better the overall prognosis is going to be. Additional therapies, such as the ones mentioned above, can guarantee a faster and better recovery from the respective injury. The living environment often has to be adapted to the needs of the patient, with occupational therapy playing a very important role in the matter. Moreover, the patient has to benefit from regular counseling, in order to deal with feelings of anger, symptoms of depression and frustration in an effective manner.

AUTHOR BIO

Katleen Brown is a health, beauty and fitness writer. She loves to publish her articles on various health related websites. In her spare time, likes to do research to bring awareness.

Recognizing the unity of body, mind, and outlook, she helps empower women to tune into their innate & inner wisdom to transform their health and truly flourish.

Get in touch with her on Google+, Pinterest and Twitter.

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NHS prescribing of gluten-free foods
Many thanks Alex (Scott-Samuel) for sending me this.  I have a severe form of coeliac disease, and  my husband also has to follow a gluten free diet. He does so due to the risk of cross contamination, as if I have a coeliac attack it triggers an Addison’s crisis which is a certain visit to A&E and can be fatal.  I have to be very careful indeed, and am an A&E frequent flyer.  Our food bills have tripled and all meals have to be prepared from scratch.  Wheat is added to almost everything, and when it isn’t the item is expensive.  Even “good” meat or chicken is not  suitable if prepared in a factory where they are also making nuggets, or sausages, and porridge isn’t gluten free unless stated.  The extra expense is for dedicated factories. A tiny third of a loaf is around £3 to £4.00. Put that with a tin of beans (only Heinz is currently gluten free that I know of) and even a lunch of beans on toast becomes expensive.   I have been told that the poorer and elderly with coeliac disease are suffering already in my area, though the CCG have said that doctors can use discretion rather than issuing a blanket ban.  I have not followed up on  that to see if it is working as it should. Now imagine someone with coeliac who has been sanctioned, or is on a zero hours contract.  Food banks, at least locally, do not take such medical needs into consideration. This will certainly widen health inequalities and shorten the lives of  poorer, and even not so poor coeliacs. There are not that many of us (see below) and there is plenty of room for negotiating on price. The arguments against  are very much along the lines of Marie Antoinette’s response to the poor having no bread and starving “let them eat cake”.

NHS SUPPORT FOR PATIENTS WITH COELIAC DISEASE

About Coeliac UK

Coeliac UK is the national charity for people with coeliac disease and dermatitis herpetiformis (DH), for nearly 50 years we’ve been improving the lives of people living without gluten through providing independent and expert information, and campaigning on their behalf for better diagnosis for coeliac disease, better care and better access to gluten free food in and out of the home.

As the only charity in the UK offering comprehensive support for coeliac disease and the gluten free diet, we are a trusted voice, advocate and partner for our community.

Summary of main points

  1. Coeliac disease is a serious medical condition where the body’s immune system attacks its own tissues when gluten is eaten. Currently, the only medical treatment for coeliac disease is strict adherence to a gluten-free diet for life.
  2. Since the late 1960s staple gluten free food has been prescribed to support dietary adherence for the prevention of long term health complications and comorbidities. This rationale is now being challenged by some Clinical Commissioning Group (CCGs) in NHS England. The reason cited is, almost universally, the need for CCGs to make savings to their prescribing budgets.
  3. A significant proportion of CCGs in England are now choosing to restrict or to remove this support for patients with coeliac disease. This is leading to significant and unwarranted variation in access to gluten free food across the country and is exacerbating health inequalities, as changes disproportionately impact the most vulnerable. NHS patients across England are now subject to a postcode lottery for NHS support once diagnosed with coeliac disease. NHS patients in Scotland, Wales and Northern Ireland continue to receive full support in the treatment of their condition.
  4. CCGs report that the price paid for products by the NHS is higher than that paid in supermarkets, yet there has been no effort to improve procurement processes, including product price negotiations.
  5. The annual Net Ingredient Cost (NIC) of gluten-free foods to NHS England was around £25.7m in 2015, or around 0.3% of the total prescribing budget for NHS England of £9.3bn.
  6. Failure to treat coeliac disease or to follow a strict gluten free diet can lead to health complications and comorbidities. This means that restricting treatment is likely to be a false economy for the NHS, as it could lead to higher treatment costs and poorer health outcomes in the long term.
  7. Recent organisational and structural changes to the NHS in England has meant that innovation or the adoption of alternative forms of support, such as pharmacy-led gluten free prescribing or voucher schemes, has been hindered. Significant efficiency savings could also be made through improved procurement, but these innovations are unlikely to be cost effective at individual CCG level.

Coeliac disease and associated long-term health complications

Coeliac disease is a serious medical condition where the body’s immune system attacks its own tissues when gluten is eaten. This causes damage to the lining of the gut and means the body cannot properly absorb nutrients from food. It is not an allergy or simple food intolerance.

Coeliac disease is an autoimmune disease that occurs in people who have the genes that predispose them to the condition. It is more common among people with other autoimmune diseases, such as Type 1 diabetes and autoimmune thyroid disease.

The long term health complications associated with untreated coeliac disease are osteoporosis, ulcerative jejunitis, intestinal malignancy, functional hyposplenism, vitamin D deficiency and iron deficiency. Currently, the only medical treatment for coeliac disease is strict adherence to a gluten free diet for life.

Background to the prescribing of gluten free staple foods

Since the late 1960s gluten free food has been prescribed to support the treatment for patients with coeliac disease. Gluten-free food is prescribed to promote dietary adherence, and thus to prevent long term health complications and comorbidities. NHS support is available to those with coeliac disease in recognition of the highly restrictive nature of the diet, the high price of gluten-free substitute foods, and the very limited choice and availability of many gluten free staple foods.

To assist clinicians and commissioners to support patients with coeliac disease, National Prescribing Guidelines for the Prescribing of Gluten-free Food have been produced by Coeliac UK, in consultation with the NHS and other professional healthcare bodies. These Guidelines are endorsed by the Primary Care Society for Gastroenterology (PCSG) and the British Dietetic Association (BDA); they are followed in Scotland, Wales, Northern Ireland and around half of the CCGs in England.1

Only gluten free products that are approved by the Advisory Committee on Borderline Substances (ACBS) and appear on Part XV of the Drug Tariff can be prescribed by GP. Products are listed on Part XV of the Drug Tariff following ACBS approval of an application by producers. The ACBS list current includes hundreds of gluten free substitute products, prices are provided by producers at the time of application and subject to annual inflation increases.

In the past, NHS policy has rightly recognised that the costs associated with the treatment of long term health complications are likely to dwarf the costs associated with prescribing gluten free staple foods, dietetic advice and monitoring. However, in some areas in England, local policies are changing to either remove, reduce or restrict this support.

The challenge on price and availability

The rationale for supporting patients with coeliac disease with prescriptions for gluten free food is now being challenged by some Clinical Commissioning Groups (CCGs). Several CCGs have highlighted improvements in access and affordability of staple gluten free foods, but have not properly researched the situation within their area of responsibility, nor presented evidence in support of these claims.

Coeliac UK has asked through Freedom of Information (FOI) requests for details of the evidence used to drive policy change in affected areas. An example of the kind of research being conducted can be found in the FOI response from North East Essex CCG, where sweeping assumptions seem to have been made devoid of any systematic research, they state:

“We appreciate that there is a large cost-differential between supermarket value brands and GF [gluten-free], but many people within the CCG buy their bread from bakers or do not buy the supermarket value brands and the cost differential is therefore much reduced.” 

This type of anecdotal evidence, which is being used by CCGs to justify decisions about patient care, is in conflict with peer reviewed research published as recently as September 2015. A study in the Cost and availability of gluten-free food in the UK: in store and online by Burden, M., et al., concluded:

“There is good availability of GF [gluten free] food in regular and quality supermarkets as well as online, but it remains significantly more expensive. Budget supermarkets which tend to be frequented by patients from lower socioeconomic classes stocked no GF foods. This poor availably and added cost is likely to impact on adherence in deprived groups.” ii

NICE recommendations and duties to reduce health inequalities

The National Health Service Act 2006 as amended by the Health and Social Care Act 2012 includes duties on the Secretary of State, the NHS England Board and CCGs to have regard for NICE quality standards. There are also legislative duties requiring CCGs to reduce inequalities with respect to access to patient services and health outcomes.

The first NICE quality standard for coeliac disease was published on 19 October (QS134) and includes a statement on the need to discuss the gluten free diet with a healthcare professional, with specialist knowledge, once diagnosed. This statement from NICE includes guidance on the equality and diversity considerations for healthcare professionals, which recognises the higher cost and limited availability of gluten free food. NICE highlights the difficulties faced by patients on low incomes or with limited mobility, and because there is a genetic component to coeliac disease, NICE also highlights the strain on household budgets where there is more than one person in the family diagnosed. NICE asks healthcare professionals to advise patients on the availability of gluten free food on prescription.

However, the lack of explicit recommendations on the need to provide access to gluten free staple food on prescription has led to CCGs in England to implement local policy change in this area, and a significant proportion are now choosing to restrict or remove all prescribing support for patients with coeliac disease.iii This removal of support is leading to significant and unwarranted variation in care across the country, and as noted above, is likely to further exacerbate health inequalities.

NICE Guidance (NG20) was reviewed in 2015, and recommends that all patients with diagnosed coeliac disease are offered an “annual review”, which should include measurement of height and weight and a review of symptoms, as well as consideration of the need for specialist dietetic or nutritional advice, or clinical referral. Implementing and establishing the NICE recommendation on annual review within local services will be imperative to enable the monitoring of patient outcomes and assess the impact resulting from local policy change.

The lack of a national prescribing policy from NHS England means considerable uncertainty for those who rely on access to gluten free staples on prescription to manage coeliac disease, and the most vulnerable are most acutely affected. In particular, those on fixed incomes or benefits who receive prescriptions free of charge, and those who are housebound and rely on deliveries from community pharmacies. The result is that NHS patients across England are now subject to a postcode lottery for NHS care and support, once diagnosed with coeliac disease.

NHS costs and procurement

The annual cost of gluten free food on prescription to NHS England was £25.7m in 2015, this was 0.3% of the total prescribing budget of £9.3bn for 2015. iv,v The main argument used for restrictions or service cancellation is the need for efficiency savings. NHS support for patients with coeliac disease is quickly becoming a “Cinderella” service.

CCGs that are restricting or preventing access to gluten-free food on prescription often argue that gluten free food is now available to purchase in large supermarkets, and that patients can do this at a lower cost than the cost to the NHS to buy gluten free staples. For example, in a letter to patients dated 16 June 2015, the North Norfolk CCG stated:

“Today these products are widely available from all supermarkets and are sold to the public at prices that are considerably lower than the NHS is charged when bought for use on prescription.”

What is surprising about this statement is that prescription services seem to be now be risk because NHS procurement teams have been unable to secure competitive prices. As stated above, the price the NHS is charged for gluten free food products are advised by producers when applying to the ACBS for product listing on Part XV of the Drug Tariff.

The total UK market value of gluten-free foods in 2015 in England was £247m, making the NHS England annual spend of circa £25.7m on gluten-free food around 10% of the total gluten-free food market. vi It would be reasonable to expect that such a significant market share provides sufficient purchasing power to negotiate prices equal to those paid by commercial retailers. Patients should not be suffering the consequences of inefficiencies within procurement systems. Pressing this point, Kevan Jones MP said during the Westminster Hall debate (November 2016):

“I do not know why the NHS cannot negotiate contracts with some commercial companies. Failure in procurement will clearly have an impact.” (Hansard Online, Volume 616)

The “patients can buy products at a lower price” position also ignores the additional benefits of appropriate support and monitoring by healthcare professionals, and the fact that this is true of a range of treatment and medicines available on the NHS. The annual cost of gluten free food staples to the NHS is significantly lower than the annual cost of other items prescribed, but available for purchase over the counter at a lower cost than that to the NHS, such as Senna (for occasional constipation) with a total cost of £32.3m and paracetamol at an annual cost of £85.1m and rising.

More importantly, this argument contradicts the principles that guide the NHS, in particular that the NHS: provides a comprehensive service, available to all; that access to NHS services is based on clinical need, not an individual’s ability to pay; and that the NHS aspires to put patients at the heart of everything it does.

Gluten free food producers

While some CCGs are not always comparing like for like products when making price assessments, there are circumstances when the NHS does pay a higher price than the retail product equivalent. Coeliac UK has approached the trade association representing gluten free food producers in the UK, the British Specialist Nutrition Association Ltd. (BSNA) to challenge them on this issue.

BSNA has reported several issues relating to increase costs, including the need to provide a universal service to all pharmacies across the country, ensuring “availability and access to a reasonable supply of staple gluten-free foods”. The use of community pharmacies ensures that all patients, regardless of where they live can access staple food when needed, including those who rely on home deliveries.

Is cutting gluten free prescribing a false economy?

The NHS is also guided by the principle of commitment to providing the best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources. This raises the issue of false economy, where small savings in prescription costs could lead to higher treatment costs associated with poor health outcomes and increased health complications. For example, the cost of gluten free staple food over a 40-year period is approximately £7,770 (£194.24 per year) and the cost of treatment for a hip fracture £12,170 (increasing by £70,000 per patient if cases become more complex).vii,viii,ix

Reducing dietary adherence, risks not only long term health complications, but is also likely to increase absences from work due to continuing ill health amongst patients who aren’t able to source or afford gluten-free foods.

This issue was raised by Liz McInnis MP, commenting during the Westminster Hall debate on 1 November, she said:

“Is the Minister aware that the annual cost per diagnosed patient of prescribing gluten-free food is £180 per year? Weight that up against the cost of avoiding infertility, bowel cancer and osteoporosis. What is the obvious conclusion for any NHS professional?” (Hansard Online, Volume 616)

The case for continued gluten free prescribing

Coeliac UK believes that it is important that gluten-free prescribing continues for the following reasons:

  1. Treatment and prevention of serious long-term health complications

Adherence to the gluten free diet is greatly improved through prescriptions for gluten free staples and regular follow-up and support. x Once treated with the gluten free diet for three to five years, the risk of developing the cancers associated with coeliac disease reduces to no greater than that of the general population.xi The risks associated with osteoporosis are largely dependent on any damage already sustained, or lack of dietary adherence, due to the inability to absorb calcium.

  1. Price

Gluten-free foods can cost around three to four times as much as their gluten containing equivalent. For example, gram for gram gluten-free bread costs up to six times that of standard bread. xii Therefore, the withdrawal of treatment impacts most significantly on those with the low or fixed incomes or those who currently receive prescriptions free of charge.

  1. Access

Gluten-free or “Free From” products tend to only be available in larger supermarkets or health food stores. The former are often out of town, and increasingly supermarkets are opting for convenience sized stores in large cities and urban centres; these stores often cannot justify the shelf space for these low turnover items. Those who rely on community pharmacy deliveries or without access to a car or the internet often have difficulties in sourcing staple foods. It has also been suggested that online ordering is a solution. However, the delivery costs and minimum order restrictions can be prohibitive for some, and because these products lack structure (due to the absence of gluten) they do not always “travel well” through parcel services.

  1. Availability

While many of us are used to the convenience of prepared or take away foods, availability of gluten-free products in these categories are extremely limited. This means that those with coeliac disease often need to make meals at home to take to work or on journeys, and therefore, need to have a range of gluten free staple foods, like bread, available at home.

The financial pressures faced by the NHS are well reported. However, service provision should be driven by clinical need and not adjusted purely on budgetary constraint. The need for NHS England to provide value for money when deciding on appropriate clinical treatment and services is recognised. However, some CCGs are now taking a short term view on health spending. This flies in the face of preventative strategies favoured by NHS England and Public Health England, and has the potential to derail this long-term sustainable spending strategy.

Innovating for efficiencies

Cutting and reducing service provision is not the only way to find efficiencies in the NHS. Service innovation, improved procurement and national collaboration also have the potential to deliver efficiencies, as well as improvements in patient experience.

Some CCGs have attempted to improve or innovate support services for patients with coeliac disease, while also looking for savings. The NHS Five Year Plan outlines use of pharmacy services to extend existing primary care resource, but there are significant hurdles in developing sustainable pharmacy-led service models using NHS England organisational and contractual arrangements.

These hurdles appear to have been cleared by NHS Scotland, through the introduction of a national pharmacy-led scheme, which allows for a patient-centred approach which improves the quality of the service while providing for greater control of costs. One of the main benefits delivered by the Gluten Free Food Service (GFFS) in Scotland is the increased capacity in GP surgeries, as community pharmacy is the site of service delivery.

The GFFS evaluation, at the conclusion of the 18-month pilot, reported from the survey of GPs “there was overwhelming support (98% n=442) for the trial GFFS to continue as an ongoing service” and similarly from the survey of community pharmacists “in the opinion of respondents, 92% (n=300), GFFS should continue as an ongoing service”. Patients also saw benefits, the evaluation reporting that “the vast majority of respondents liked the service (90% n=1,284) and want it to continue (93% n=1,318)”.xiii

Some CCGs in England are innovating with the aim of reducing costs in all prescribing. NICE published a Quality and Productivity Case Study in 2014 from Walsall CCG, which provides a practical example of how savings can be made, the CCG implemented a pharmacist-led repeat prescription management service:

“The service was aimed at reducing medicines wastage, minimising possible harm from medicines and improving the quality of repeat prescribing. Cash was saved by ensuring the least expensive, clinically appropriate medicines were prescribed by switching from branded to generic drugs. Practice-based pharmacists worked as an integral part of primary care general practice teams to manage repeat prescriptions.

For the financial year 2013/14 the service delivered net savings of £610,270 and demonstrated that for every £1 invested in pharmacist time there was a saving of £3.05”.xiv

Capacity in GP surgeries can also be gained through repeat dispensing. Around two thirds of all NHS prescribing in primary care is for patients that require repeat supplies of medicines, food or equipment. Repeat dispensing is available to increase patient choice and convenience, to minimise wastage by reducing the number of products dispense which are not required by the patient and to improve GP capacity by lowering the burden of repeat prescriptions.

For these reasons, since 2005 repeat dispensing has been an Essential Services within the Community Pharmacy Contractual Framework (CPCF). However, according the Pharmaceutical Services Negotiating Committee (PSNC) take up as been very low. The PSNC reports that:

Despite the benefits that the service can bring to patients and the NHS, uptake of it has been very low, in part due to lack of engagement by GP practices. In order to increase the benefits being gained by patients and the NHS from this service, it was agreed in September 2014 that from 1 March 2015 there will be a new requirement in the CPCF for pharmacies to give advice to appropriate patients about the benefits of the repeat dispensing service.”

As well as using existing models to drive efficiencies, new schemes are being considered. The Vale of York CCG is trialling a new voucher scheme, or pre-loaded payment card, as a way of helping patients to access gluten free staples from local supermarkets. Coeliac UK supports these innovations, if supported by a positive evaluation of patient outcomes and ongoing monitoring. This scheme is delivering some local benefits, but is likely to need national support from supermarkets and scale to ensure it delivers the savings that warrant set up and administrative costs. This idea was supported by Kevin Foster MP in November 2016, he asked the Parliamentary Under-Secretary of State for Health:

“Will he suggest to CCGS such as Torbay in south Devon that there is a halfway house and that instead of scrapping the prescription of gluten-free products they could provide vouchers that could be taken to a local supermarket?”(Hansard Online, Volume 616)

Other possibilities, not yet being piloted, include web based e-commerce ordering systems, where all products approved for purchase can be loaded on to the site and paid for using a secure wallet (electronic allocation). The patient can then select the retailer, pharmacy or store to arrange a collection.

Such a system could deliver significant savings to the NHS in clinician time and administration for NHS England. However, to be cost effective, such a scheme would need to be developed as a national service, not separate services in 209 CCG areas. All schemes need to be teamed with appropriate local dietary and health support and monitoring or “annual review”.

 

 

 

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STD. STI. Whatever you call it, a sexually transmitted disease or infection is absolutely no fun for anyone. Unfortunately, it’s very easy to catch gonorrhea, chlamydia, HPV and other wellness-wrecking disorders. The good news is, most sexually shared diseases can be cured. But first, you’ve got to know that you have one. There are certain times in life when it’s a good idea to get tested for sexually transmitted infections, no matter who you are.

Why everyone should be tested for an STD

First, it’s in your best interest to understand that not every person who’s infected with a sexually transmitted disease knows it. Some people experience no symptoms at all. Others are unaware of their own infection until an intimate partner shares the dire news. If you’re about to enter into a new sexual relationship, or if you plan to resume an older relationship, both partners ought to be tested, just to make sure they are both uninfected. If you’re worried about your confidentiality, explore your STD testing options to find a clinic near you that promises privacy.

The Centers for Disease Control are experts where sexually transmitted diseases are concerned. The CDC recommends that every adolescent and adult between the age of 13 and 64 be tested a minimum of one time for HPV. The human papilloma virus can lie dormant for years, so testing is crucial to prevent the spread of genital warts.

Sexually active females may protect their health by undergoing chlamydia testing every year. Pregnancy is another imperative time of life when women should be tested for chlamydia, gonorrhea, syphilis, HPV, HIV and any other diseases they may have been exposed to. Many STDs can be passed from mother to baby, so screening for STD during pregnancy actually protects at least two people.

HIV can be spread through sexual contact and shared needles, too. For this reason, anyone who uses injectable drugs should seek testing for HIV regularly, says the CDC. Testing for this and other potential infections protects the user, their friends, and society as a whole. Most communities have at least one clinic where anyone can obtain confidential HIV testing for low or no cost. If you have health insurance, or if you are covered by someone else’s policy, you can request communications confidentiality with a phone call or by filling out a simple form at MyHealthMyInfo. This means that minors who seek STD testing can do so without their parents being informed by the insurer.

Timing is everything

If you think you should get tested for gonorrhea or another STD the day after you’ve had relations with a new sex partner, do think again. According to sex experts at Bustle magazine, STDs have to be in your body a little while before they show up on a test. Some infections, such as gonorrhea and chlamydia, take around two weeks to show up. Some forms of hepatitis may be evident in one month if you submit to a ‘rapid test’ for a liver infection. HIV is like that, too. Generally, however, both HIV and hepatitis can take as long as six months to be detectable by a typical antibody test.

Depending on how sexually active you are, you ought to seek STD testing as often as every three months. If you and your monogamous partner tested clean at the beginning of your relationship, annual testing may be appropriate. If you have more than one partner, you should do the every-three-months testing routine, even if you use a condom every time. While a high-quality condom worn the right way may indeed prevent most pregnancy and lessen the likelihood of most kinds of STD transmission, they’re still not 100 percent effective. Even a tiny amount of pre-ejaculate or vaginal fluid can carry a lot of infectious microbes.

Do it for your future

If you have an STD and you don’t have it treated appropriately and effectively, it can lead to a whole lot of health trouble down the road. If left unchecked, syphilis can cause insanity and blindness. Really. Gonorrhea can cause sterility, the inability to ever have babies. If a woman does get pregnant while infected, she may experience serious complications and even share the disease with her baby.

Protect your current health and your future health, too. Find a free clinic in your neighborhood and get tested for STD. Do it as if your life depends on it because it really does.

Natalie Martin is a freelance writer, and when she is not working on her next article she can usually be found in her garden. She attended the University of Cincinnati before turning to writing and now spends much of her time drawing attention to some of the major health problems that are plaguing the country today. Natalie resides along the Gulf Coast with her 6-year-old Labrador Retriever.

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It’s not uncommon to suffer from a sleep disorder. If you search for sleep disorders online you will find a vast array listed. But which sleep disorders are the most common? What are the symptoms of these disorders? What treatments are available?

The aim of this article is to examine three of the most common sleep disorders and the help and treatments used to alleviate them. We also also going to tell you about other factors that may be leading to you not getting the sleep that you need.

    1. Insomnia

Insomnia affects as many as half the population at some point in their lives. The problem can be acute or chronic. Acute insomnia is short lived, whereas chronic insomnia lasts for long periods of time. If you have trouble getting to sleep at night, your sleep is disturbed, or you wake up earlier than you should, you may be diagnosed with insomnia.

There can be many different causes of insomnia, including stress and issues with the environment around you. We are going to take a closer look at environmental issues later in this article. If you are worried or stressed then you may find stress relieving techniques useful. If insomnia is a problem you should also seek medical advice.

    1. Sleep Apnea

Sleep Apnea is another common sleep disorder; in fact it could be even more common than we think because many people do not know that they have it. Sleep Apnea occurs when the soft tissues in a person’s throat relax. This acts to block the passage of oxygen to the lungs. When the blockage is only partial this can cause snoring. If the blockage is more severe, breathing often stops and then quickly resumes. The problem is that the brain is required to jump into action at this point and does not get the rest it needs.

If mild Sleep Apnea is diagnosed it may be that a lifestyle change can help; such as giving up alcohol or losing weight. If the problem is more severe the most common form of treatment is continuous positive airway pressure (CPAP).

    1. Restless leg syndrome

Strictly speaking, this is not only a sleep disorder as it can affect sufferers any time they rest. The condition results in a need to move the legs, or sometimes other limbs. This is due to a variety of sensations, including jumping, burning and aching.

There can be a genetic link with sufferers of restless leg syndrome (RLS). Medical conditions such as diabetes and kidney failure can also be an underlying cause. If there is an underlying cause, treating this often helps alleviate the symptoms of RLS. Other suggested treatments or aids include regular leg massage and reducing alcohol and nicotine intake.

    1. What else can you do to help you sleep?

Whether or not you have been diagnosed with a sleep disorder, there are certain things you can do to help you get the sleep you need.

  • If your mattress is wearing out, take a look at Ikea mattresses to find a firmer replacement.

  • Switch off electrical appliances that emit blue light before you sleep.

  • Ensure your bedroom is as dark as possible.

  • Adopt a relaxing routine before bed; such as taking a warm bath.

All of these tips should help improve your sleep pattern. If you think you are being affected by any of the sleep disorders we have mentioned you should seek medical advice.

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It goes without saying that you need your heart to beat to a regular rhythm if you are going to enjoy a normal healthy life and be able to exercise regularly.

If you have suspicions that perhaps things aren’t quite what they should be and you notice your heart racing or you feel abnormally sweaty and faint, these are just some of the symptoms that could suggest you have a heart rhythm disorder.

Here is a look at some of the signs to look out for, plus an insight into what causes this disorder and what options are available to resolve the problem. There is an overview of the different types of arrhythmia and details of how your lifestyle choices could affect your heart rate.

Not always obvious

If you experience chest pain or suffer bouts of fainting these are two classic symptoms, that suggest you have some form of heart arrhythmia, but it should also be noted that it can be the case that you don’t display any signs or symptoms to indicate there is a problem.

This is a real dilemma when you don’t display any symptoms, but in those circumstances, it is possible that your doctor might discover that you have an arrhythmia before you know about it yourself.

To complicate matters further, even when you do display some of the regular symptoms, it doesn’t necessarily follow that you have a serious problem with your heart.

The main point to take on board is to be vigilant and don’t ignore any issues that could suggest you need to get a professional opinion before it becomes a more serious problem.

Warning signs

Although some people don’t display any noticeable symptoms there are certain tell-tale physical reactions that should not be ignored.

A fluttering in your chest that feels a bit like butterflies inside is one potential sign of an issue, as is a heartbeat that feels like it is racing too fast, which is known as tachycardia, or the opposite scenario where your heart rate is too slow for comfort, which is called bradycardia.

You might also experience chest pains, a noticeable shortness of breath, or a definite feeling of lightheadedness. Feeling dizzy, sweating more than usual or feeling like you are about to faint, are also noticeable arrhythmia symptoms.

Better to be safe than sorry

It should be said that arrhythmias are very common, especially as you get older, and for millions of us they are harmless and don’t require any further treatment.

The problem you have is that for some of us, this is definitely not the case and some arrhythmias can be very dangerous and even life-threatening, so it is never a good idea to ignore any noticeable symptoms as it is always better to get yourself checked out rather than leave anything to chance.

Probable cause

There are ways to regulate your heartbeat and protect yourself from the effects of a dangerous arrhythmia, using solutions available through someone like http://www.abbottep.com/, but one of the questions you might want to ask before you get to that point is what can cause arrhythmia in the first place?

A more extreme example of an incident that is causing an arrhythmia to occur would be if you were actually having a heart attack at that point, or it can happen if you suffered any scarring of your heart tissue when you had a heart attack previously.

Blocked arteries and high blood pressure are also probable causes as are problems with an overactive or underactive thyroid gland.

Your lifestyle could also be a major contributory factor as you are potentially more susceptible to an arrhythmia if you are a smoker, drink too much alcohol or consume large amounts of caffeine, or suffer from stress.

Identifying the problem

There are many different types of arrhythmia and they are classified by doctors in two specific ways.

The first is where the arrhythmia originates from, which will be either atria or ventricles, secondly, the speed of the heart rate that they cause.

If you do have an issue, you will probably be told that you either have tachycardia (fast heartbeat) or bradycardia (slow heartbeat).

It doesn’t mean that you a heart disease if you have either of these conditions, but the fundamental point about all of these symptoms and conditions is that you need to get a professional opinion so that you know if you are at risk and what action needs to be taken to regulate your heartbeat.

Tom Cartwright is a medical student who pens an article or two when time allows between his studies. His articles appear on health related websites.

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Most of us accept that as we get older our eyesight is likely to get worse. Very few people with normal vision get through life without finding it hard to read the small print, and the vast majority of us are using glasses or contact lenses by the time we hit our sixties. But that doesn’t mean we can be completely relaxed about deteriorating vision. Some eye problems can lead to serious conditions that can be avoided if caught early enough. That is why it is so important to have regular eye checks.

Where Does the Problem Lie?

For vision to be optimum, the light has to pass through several different tissues. A problem with any of these will disrupt sight and may lead to further problems.

  • The cornea is the clear window at the front of the eyeball
  • The aqueous humor is the liquid behind the cornea
  • The lens focuses the light onto the retina
  • The vitreous humor fills the eyeball behind the lens
  • The retina is the nerve covered tissue that receives the light and converts it into nerve impulses
  • The optic nerve carries the impulses to the brain

The Cornea

The cornea, as the only part of the eye exposed to the air, is susceptible to a variety of different problems. It can be infected or damaged. A common condition is conjunctivitis, an irritating inflammation of the surface of the cornea and of the inner eyelid.

Damage to the cornea can cause a number of symptoms, like redness, watering, or changed vision. The treatment depends on the cause, but in severe chronic cases, a corneal transplant may be required.

Although not required by a problem with the cornea itself, some treatments for poor vision, such as the LASIK surgery carried out by John D. Goosey, M.D. effectively adjust vision by changing the shape of the cornea.

The Lens

With age, the lens loses its elasticity, and this is the cause of presbyopia, the difficulty of close focusing that comes with age for most people.

The most common serious (though painless) problem affecting the lens is the development of cataracts, making the lens cloudy and opaque. Eventually, it leads to blindness but can be corrected by removing the lens in a straightforward operation.

The Humors

Glaucoma is a very serious condition in which the aqueous humor in the front of the eye does not circulate or drain properly. This causes a build-up of pressure throughout the eye which can cause the optic nerve to fail. It is a painless condition that builds up over many years, especially in those with a family history. It is one of the most important reasons for regular eye checks.

Floaters are little black dots that can appear in the field of vision. They are tiny opacities in the vitreous humor which become more common with age. Normally they are just a nuisance that your brain will adjust to, but they should be checked, especially if they are accompanied by flashes of light, as they may be a symptom of a developing problem with the retina.

The Retina

The retina is a mass of nerve receptors. It can only function when it is firmly attached to the back of the eyeball; if it becomes detached from its blood supply it rapidly dies. Therefore a detached retina must be treated as a high priority. Its symptoms are normally floaters and flashes, blurred vision, or blind spots. There are various treatments including laser therapy and the injection of a bubble of gas or oil to press the retina back against the eyeball surface.

Another common problem with the retina is age-related macular degeneration, where the main concentration of retinal receptors degenerate, and vision becomes vague. It is not curable, but early treatment can control the symptoms with medication or prescription glasses.

In Short

The protection of our eyesight is a priority for everyone. Although with the passing of years eyesight issues become more likely, problems can occur at any age. Diabetics are also at particular risk of complications affecting vision. The most important advice is to have regular eye checks by a qualified person, which will give early warning of the most likely conditions. Also seek an immediate consultation if you have any sudden change of vision, especially a sudden blurring or complete loss of areas of vision. That way you stand the best chance of preventing a lasting or incurable loss of sight.

Taina Schuster Marketing specialist with 7+ years of experience in Digital Marketing, Advertising and Project Management. Worked and led projects and campaigns within various industries, such as Retail, Food & Beverage, Entertainment, Healthcare and Oil & Gas.

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