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    The UK-CAB is the UK’s HIV treatment advocates network.
     
    A couple of weeks ago four UK-CAB members spoke to Dr Rageshri Dhairyawan from Barts Health NHS Trust. It was a chance for HIV positive people from BAME communities to voice their concerns about the coronavirus pandemic. The strong focus was on questions from people living with HIV and the communities they work in.

    Watch via YouTube: https://youtu.be/Cy7d7FD2ro0

    The recording is about 40 minutes long. It covers a wide range of questions in relation to COVID-19. Discussion covers inequalities in health care, sexual health, mental health, research, stigma and HIV treatment. 

     

    We hope this film provides an educational tool for doctors and the public. Please share it with people accessing your services, clients, partners, and friends and families. 


    Thank you to Adela, Jide, Juddy and Shamal for taking part and to Jo for chairing this session, and of course to Dr Rageshri for answering these important questions.
     
    And, here is Dr Ameen Kamlana in a very short interview with Sky News on how COVID-19 is disproportionately affecting people of colour.
    Comments Off on COVID-19: BAME communities living with HIV and a short interview with Dr Ameen Kamlana
    Thousands of social care staff in England could be falling through the net when it comes to the provision of the £60,000 payment in the event of death due to Covid-19.
    Serious concern was expressed today (Friday 22 May) by Unite, Britain and Ireland’s largest union, which has combed through the small print as to who the payment applies to.
    According to the government document, Coronavirus Life Assurance Scheme – Death in Service (England only): ‘Any employee who works for a private social care organisation which receives no public funding’ is not eligible for the payment.
    Unite called on health and social care secretary Matt Hancock to clarify and rectify the situation as a matter of urgency, given that more than 300 NHS and social care workers have now died as a result of Covid-19.
    Unite assistant general secretary Gail Cartmail said: “Matt Hancock needs to clarify what the small print actually means, as it is totally unacceptable that possibly thousands of social care workers are barred from this scheme because their place of work has no public funding.
    “We can’t have this two-tier situation where one care worker’s contribution, fighting coronavirus, is regarded of less value than another in a different setting. If you are risking your life in the battle against Covid-19, your workplace and how it is funded are irrelevant.
    “We don’t know the true scale of the problem across England – it could be that thousands of care workers are being denied this cover – but if it is only one, it is one too many.
    “Unfortunately, the health trade unions have not been consulted in drawing up this eligibility criteria in England – if we had been, we would have objected in the strongest possible terms to what is now in place.
    “The government has shown that it is capable of righting a wrong, as was proved yesterday with the U-turn on the £400 charge for NHS migrant workers. This is another case where a ministerial rethink is in order.”
    Last month, Matt Hancock announced that families of NHS and social care workers, who have died after contracting coronavirus in the course of their duties, will receive a £60,000 payment from the taxpayer.
     
    Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org
    Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

     

    Comments Off on Thousands of care workers could be ineligible for £60,000 Covid-19 payment, warns Unite

    From Vivien Walsh in Manchester

    Right at the beginning of the lockdown, several of my friends said how concerned they were about the likely impact of enforced social isolation on those who are suffering from domestic abuse. On Monday, the (cross party) Home Affairs Committee of MPs, chaired by Yvette Cooper, reported on this, demanding “that the Government makes domestic violence and abuse a central pillar of the broader strategy to combat the Covid-19 epidemic.”

    Calls to domestic violence helplines, such as Refuge and Women’s Aid, were nearly 50% higher in the week 6-12 April than the average before the pandemic began. Visits to the website of Refuge were three times as high in March 2020 as they were in March 2019. The Home Affairs Committee called for this domestic violence strategy to combine “awareness, prevention, victim support, housing and a criminal justice response, backed by dedicated funding and ministerial leadership”.

    It also made a point of the need for specialist services for different ethnic communities, and for legal aid as an automatic right for women applying for Domestic Violence Protection Orders (DVPOs). An extension of the current time limit for reporting offences is also necessary, since many abused women will be unable to report the abuse they have suffered until after lockdown ends.

    Between March 23 and April 12 there were at least 16 killings of women and children in domestic situations, said the report on Monday. The average number of deaths from domestic violence during lockdown has gone up from 5 per week from a figure of two before. In a year that would be over 250 women killed by the person who is supposed to love them. The Parliamentary Committee had also received evidence that incidents reported were not only more frequent but involved higher levels of violence and coercive control.

    Unless the government takes action to deal effectively with domestic abuse and to properly support the victims of it, we will be facing “devastating consequences for a generation.” Funding is urgently needed to enable a growth in provision of housing for women and children escaping from violence, and to support refuges as temporary accommodation and support. Even before current emergency, England had 30% fewer than the recommended number of beds, and 64% of referrals were turned down in 2018-19.

    There is a National Domestic Violence Helpline (0808 200 247). This is the number to call for  emergency referrals as they are open 24/7. In addition there a variety of services based locally. For example Manchester Women’s Aid (call 0161 660 7999  9:30am-4:30pm Mon-Fri) provides confidential advice and information, safe temporary housing, one to one support for those living in their own homes, access to legal advice and civil orders, specialist workshops for young women 15-25, language workers and access to interpreters, specialist support for women with poor mental health and drug and alcohol misuse. The full list of services in England and Wales is at the end of the article.

    The lockdown is in place to keep people safe from the virus: but it is also providing cover for abusers. Escape from being locked in with an abuser is a matter of life and death. A decade of austerity has not only undermined our NHS, on which we are now so dependent, but has also decimated support for survivors of domestic violence. The Government must increase funding as a matter of urgency – and there will be just as much need for services as abused women and children try to return to “normal” life when the lockdown is over. And Children’s services also need a big increase in funding to make sure children as risk, not only from the mental and physical impact of domestic violence, have access to help and support.

    Amna Abdullatif (whose day job is Women’s Aid lead for Children and Young People, and who is also a Manchester City Councillor) added the following information for the SHA in this blog: “78% of survivors experiencing domestic abuse told us that Covid-19 has made it harder for them to leave their abuser. If you’re feeling trapped, we’re here for you.”

    “Our Live Chat is now open from 10am – 2pm with expert support workers just one click away. You can be reassured that our Live Chat is completely confidential. To access support and advice go to: https://bit.ly/2y7ab0Q

    “If you, or someone you know, is experiencing abuse please read our Covid-19 safety advice for survivors, family, friends and community members https://bit.ly/2yNzqoW

    There are also local services for ethnic groups, such as Saheli Asian Women’s Project in Manchester, which provides advice, information and support services to Asian women and their children fleeing domestic abuse and/or forced marriages.

    The full list of services from the Womens Aid web site is below:

    National Domestic Abuse Helpline

    The National Domestic Abuse Helpline is run by Refuge and offers free, confidential support 24 hours a day to victims and those who are worried about friends and loved ones.

    Telephone and TypeTalk: 0808 2000 247

    Wales Live Fear Free Helpline

    The Wales Live Fear Free Helpline offers help and advice about violence against women, domestic abuse and sexual violence.

    Telephone: 0808 8010 800

    TypeTalk: 18001 080 8801

    Text: 078600 77 333

    The Men’s Advice Line

    The Men’s Advice Line is a confidential helpline for male victims of domestic abuse and those supporting them.

    Telephone: 0808 801 0327

    Email: info@mensadviceline.org.uk

    Galop – for members of the LGBT+ community

    Galop runs the National LGBT+ domestic abuse helpline.

    Telephone: 0800 999 5428

    TypeTalk: 18001 020 7704 2040

    Email: help@galop.org.uk

    Women’s Aid

    Women’s Aid has a live chat service available Mondays to Fridays between 10am and 12pm as well as an online survivor’s forum. You can also find your local domestic abuse service on their website.

    The Survivor’s Handbook, created by Women’s Aid, provides information on housing, money, helping your children and your legal rights.

    Karma Nirvana

    Karma Nirvana runs a national honour-based abuse and forced marriage helpline. If you are unable to call or email, you can send a message securely on the website.

    Telephone: 0800 5999 247

    Email: support@karmanirvana.org.uk

    Hestia

    Hestia provides a free mobile app, Bright Sky, which provides support and information to anyone who may be in an abusive relationship or those concerned about someone they know.

    Chayn

    Chayn provides online help and resources in a number of languages about identifying manipulative situations and how friends can support those being abused.

    Imkaan

    Imkaan are a women’s organisation addressing violence against black and minority women and girls.

    Southall Black Sisters

    Southall Black Sisters offer advocacy and information to Asian and Afro-Caribbean women suffering abuse.

    Stay Safe East

    Stay Safe East provides advocacy and support services to disabled victims and survivors of abuse.

    Telephone: 020 8519 7241

    Text: 07587 134 122

    Email: enquiries@staysafe-east.org.uk

    SignHealth

    SignHealth provides domestic abuse service support for deaf people in British Sign Language (BSL).

    Telephone: 020 3947 2601

    Text/WhatsApp/Facetime: 07970 350366

    Email: da@signhealth.org.uk

    Shelter

    Shelter provide free confidential information, support and legal advice on all housing and homelessness issues including a webchat service.

    Sexual Assault Referral Centres

    Sexual Assault Referral Centres provide advice and support services to victims and survivors of sexual assault or abuse.

    Get help if you think you may be an abuser

    If you are concerned that you or someone you know may be an abuser, there is support available.

    Respect is an anonymous and confidential helpline for men and women who are harming their partners and families. The helpline also takes calls from partners or ex-partners, friends and relatives who are concerned about perpetrators. A webchat service is available Wednesdays, Thursdays and Fridays from 10am to 11am and from 3pm to 4pm.

    Telephone: 0808 802 4040

    Get help for children and young people

    NSPCC

    The NSPCC helpline is available for advice and support for anyone with concerns about a child.

    The NSPCC has issued guidance for spotting and reporting the signs of abuse.

    Telephone: 0808 800 5000

    Email: help@nspcc.org.uk

    If you are deaf or hard of hearing, you can contact the NSPCC via SignVideo using your webcam. SignVideo, using British Sign Language, is available on PC, Mac, iOS (iPhone/iPad) and Android smartphones (4.2 or above). This service is available Monday to Friday from 8am to 8pm and Saturdays from 8am to 1pm.

    Childline

    Childline provides help and support to children and young people.

    Telephone: 0800 1111

    Barnardo’s

    Barnardo’s provide support to families affected by domestic abuse.

    Family Lives

    Family Lives provide support through online forums.

    Support for employers

    Employers’ Initiative on Domestic Abuse

    The Employers’ Initiative on Domestic Abuse website provides resources to support employers including an employers’ toolkit.

    Support for professionals

    SafeLives provides guidance and support to professionals and those working in the domestic abuse sector, as well as additional advice for those at risk.

    Support a friend if they’re being abused

    If you’re worried a friend is being abused, let them know you’ve noticed something is wrong. Neighbours and community members can be a life-line for those living with domestic abuse. Look out for your neighbours, if someone reaches out to you there is advice on this page about how to respond. They might not be ready to talk, but try to find quiet times when they can talk if they choose to. If someone confides in you that they’re suffering domestic abuse:

    • listen, and take care not to blame them
    • acknowledge it takes strength to talk to someone about experiencing abuse
    • give them time to talk, but don’t push them to talk if they don’t want to
    • acknowledge they’re in a frightening and difficult situation
    • tell them nobody deserves to be threatened or beaten, despite what the abuser has said
    • support them as a friend – encourage them to express their feelings, and allow them to make their own decisions
    • don’t tell them to leave the relationship if they’re not ready – that’s their decision
    • ask if they have suffered physical harm – if so, offer to go with them to a hospital or GP
    • help them report the assault to the police if they choose to
    • be ready to provide information on organisations that offer help for people experiencing domestic abuse

    If you are worried that a friend, neighbour or loved one is a victim of domestic abuse then you can call the National Domestic Abuse Helpline for free and confidential advice, 24 hours a day on 0808 2000 247.

    Comments Off on News from the Frontline 01.05.20

    The pharmacists’ trade union, PDA, has called on all pharmacy employers to immediately adopt a “zero tolerance” approach towards abuse of pharmacists supported with clear statements to patients and 100% enforcement measures that make the safety of pharmacists and their teams a clear and consistent priority.

    The long running PDA campaign to end abuse and violence in pharmacies has recently gained significant prominence as incidents of abuse and violence experienced in pharmacies has increased during the COVID crisis. The campaign has now brought the issue to the attention of politicians, police forces and the general public.  ITV evening news and News at Ten on 9 April reported preliminary results of a PDA survey exposing the reality of abuse of pharmacists and their teams and the PDA are now sharing the final results after the survey finished on Easter Monday.

    PDA Director, Paul Day said “We know this isn’t all patients, nor the experience of a pharmacists every single day, but one incident of abuse or one assault is one too many and suggesting such behaviour can ever be excused creates an atmosphere that puts pharmacy teams at risk of further attacks. How can any pharmacy employer think that this could be acceptable? 

    The survey had more than 1,200 responses in less than a week and revealed the following key results:

    • In the past month more than 90% of respondents have seen incidents where patients/customers have behaved abusively or aggressively towards them or their colleagues.
    • More than 80% noticed that the number of abusive or aggressive incidents has increased in the past month compared to normal levels.

    The survey respondents reflected the scope of PDA membership with respondents from across the UK and across the profession. A majority of respondents from each sector of pharmacy had seen abuse, but those in community pharmacy had seen it significantly more frequently than others.

    The examples provided by respondents to the survey make disturbing reading generating a 40 page report detailing verbal abuse, intimidation, threats, racism, sexism and physical attacks. While the PDA believe decent employers would, and do, naturally want zero tolerance of such treatment of their employees the following two quotes suggest that some pharmacists experience what might be described as the opposite of zero tolerance:

    “Same man has made multiple pharmacy members cry. Was very aggressive and threatened me. Told xxxxx [the major pharmacy employer] about him and they did absolutely nothing. In fact, they offered him vouchers as he complained that we were rude. We literally have no support from anyone especially large multiples such as xxxxx who I work for who will do nothing about it.”

    “I did have a particularly nasty incident whilst working for a large multiple xxxxx . A male customer came in with an incompletely written CD prescription for a relative. It was a Sunday. I told him I couldn’t accept the prescription as it was incomplete and needed to contact the prescriber. This opened up a torrent of abuse. No support staff were nearby and there was no security and I was pregnant at the time. It made me feel very vulnerable. He told me he’d make sure I lost my job and hoped that I got cancer amongst all the f… words. I reported it to xxxxx on the Monday and they said he’d been in touch and threatened to give xxxxx bad publicity. They told me they sent him vouchers !”

    Mr Day concluded: “Any degree of abuse is unacceptable but it becomes even more worrying that we are aware of several very recent incidents that have involved physical attacks after which the police have been involved.  We made sure that the Assaults on Emergency Workers (Offences) Act 2018 carries greater penalties for attacking pharmacists, but our focus is on preventing attacks in the first place

    Being able to abuse pharmacy staff without consequences creates no deterrent for potential aggressors.   This cannot be allowed to continue and employers need to play their part. Introducing a genuine zero tolerance approach would be welcomed by employees and locums who all have a right to go to work without fear of abuse or attack”

    Last week the PDA called on the Company Chemists Association (CCA) to ask it’s members to adopt zero tolerance of abuse of pharmacists,   Read More.

    Comments Off on PDA say zero tolerance needed in pharmacies to stop verbal abuse, intimidation, threats, racist, sexist and physical attacks.

    29th February 2020 the chairman of the Commons Health Committee, and former Tory health secretary, Jeremy Hunt said that we need to consider the ‘social and economic trade-offs’ we are willing to make to contain Covid-19.

    TUC General Secretary Frances O’Grady has said:

    Employers have a duty of care to support workers affected by coronavirus. No one should have to worry about making ends meet if they have to self-isolate or if they fall ill. They should be able to focus on getting better.

    The threat of coronavirus shows why sick pay should be a day one right for everybody. It’s unacceptable that millions of UK workers miss out on this protection. The Government must ensure everyone gets statutory sick pay, however much they earn.

    The SHA strongly supports the view of the TUC and urges that this scheme is extended to those on ‘self employment’ contracts – part of the 3 million plus ‘Gig economy’. We would argue further that employers should make up SSP to the average pay of workers to ensure they are under absolutely no financial pressure to attend work while they are unwell and may inadvertently pass on the disease.

    Should the coronavirus outbreak spread significantly everyone will be expected to respond putting the interests of the community first. Undoubtedly workers will volunteer long hours and take on exceptional responsibilities. This will increase the risk of errors which will need to be balanced against the risk of failure to treat patients in a mass outbreak. We urge professional bodies to be aware of this.

    The SHA congratulates trade union and Labour leaders for engaging with the government and employers and instructs our incoming leadership to move very rapidly to promote this position through forceful lobbying, online petitions and other appropriate means.

    During the debate important points were raised regarding:

    1.) Enforced quarantine – it should be paid in full.

    2.) Government requisition private care facilities if circumstances require it.

    3.) Government to consider early releases of prisoners not judged to be a risk to society – because of high COVID-19 spread risk in confined overcrowded prison populations (also note criminalisation of sections of society).

    2 Comments

    It is truly shocking that life expectancy has stalled in England, and for poorest women it has fallen.  The Marmot Review: 10 years on[1] published this week, shows us in detail how we have failed to improve on most of the indicators that were highlighted in the original review[2] 10 years ago. It points out that this can be clearly linked to the lack of implementation of those evidence-based recommendations.

    The report looks at five of the six domains that were used in the 2010 report:

    1. Give every child the best start in life
    2. Enable all children, young people and adults to maximise their  capabilities  and  have  control  of  their lives
    3. Create fair employment and good work for all
    4. Ensure a healthy standard of living for all
    5. Create and develop healthy and sustainable places and communities
    6. Strengthen the role and impact of ill health prevention

    It is interesting that they chose not to look at the sixth domain, on the grounds that plenty has been written on this area since 2010, and review was not necessary. This will ensure that there is no opportunity for Government to respond with messages about what it done in this domain, while evidence shows this to be the least cost-effective approach, and hence should have been lowest priority for policy and action.

    We know that the top priority should be our children and young people. It is very worrying that infant mortality has increased in the poorest families, that child poverty has increased and now stands at over 4 million. It shows how tax and benefits changes have been deeply regressive, pushing many families into the poverty trap. Knife crime is more common in those areas where youth services have been cut the most. A positive finding is that poor children appear to thrive better in poorer areas than in richer ones: either they are more socially excluded and stressed in affluent areas or that children and education services are doing something right in more deprived areas.

    Income is a massively important determinant of health. This report highlights how work is good for health only if it is good quality work. So, although employment has increased, this isn’t enough for people to feel the benefits. The report notes that the average weekly earnings at 2015 prices were £502 in September 2019, only £5 higher than in 2008. The UK is one of only five of the 35 OECD countries where the purchasing power of the average wage has fallen since 2008. Since 2008 there has been a large reduction in benefits available for working age people and children. This, together with the rise in housing costs, has been the driver for huge increases in food bank use. The most deprived households would now have to use over 70% of their disposable income on food if they wanted to follow the Eatwell guide for healthy nutrition.

    The report highlights social cohesion throughout, and describes forgotten communities:

    “there are   more   areas   of   intense   deprivation   in   the   North, Midlands   and in southern coastal towns than in the rest of England, whilst other parts of England have thrived in the last ten years, these areas have been left ignored. Since 2010 government spending has decreased most in the most deprived places and cuts in services outside health and social care have hit more deprived communities the hardest”

    We welcome this report. It confirms the SHA conviction that austerity kills and that the policies of the Conservative-led governments since 2010 have directly led to a heavy burden of increased mortality, ill health and misery that is largely carried by the poor. The most effective actions should have been to address the wider determinants of heath rather than individual behaviour change. Polices have in fact done the opposite of this, including the Government Prevention Green Paper a year ago. This report shows how investment for most things that affect the wider determinants of health has instead been reduced in more deprived communities.

    It would be of interest to compare the data collected here with similar analyses in the other devolved nations which have attempted to mitigate the impact of UK wide austerity policies from Westminster.

    Prof Sir Marmot says:

    ‘If health has stopped improving, it’s a sign that society has stopped improving. When a society is flourishing, health tends to flourish’

    The SHA realises that there is a very powerful lobby that will undermine this report and all the other emerging evidence, for political reasons.  We know that this report will be challenged by those who support right wing policies, and its conclusions ignored by those with an agenda that doesn’t believe in equity.

    We must do all we can to reach agreement again on what a flourishing society looks like. We must change and strengthen our democracy to be more accountable to the multiple views in our communities. The report says

    “Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

    And as socialists, we believe that the state does have a crucial in protecting and improving the health of its people. For the last 10 years, our Government has been actively undermining the wellbeing of all but the most affluent.

    [1] The Marmot Review; 10 years on, Institute of Health Equity http://www.instituteofhealthequity.org/the-marmot-review-10-years-on

    [2] Fair Society, Healthy Lives, 2010 Institute of Health Equity http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

    Comments Off on SHA responds to Marmot Report on health equity in England

    The Marmot Review 10 years on is being launched today, and is making headlines

    Key messages:

    • Over the last decade health inequalities have widened overall, and the amount of time people spend in poor health has increased since 2010.
    • #Marmot2020 confirms an increase in the north/south health gap, where the largest decreases were seen in the most deprived 10% of neighbourhoods in the North East, and the largest increases in the least deprived 10% of neighbourhoods in London.
    • The 10-year on review discounts the theory that the slowdown in life expectancy increase can be solely attributed to severe winters or flu.

    You can see the report here

    Follow twitter tag #Marmot2020

     

    Kathrin

    Comments Off on Marmot Review 10 years on says health inequalities worse

     

    Make the UK the safest place world to have a baby!

    Why is the UK still not in the top ten countries for infant mortality and for maternal deaths? Why? We are a rich country. We have an established high-quality health service. Healthcare is supposed to be accessible to all. How come babies and mothers die or are badly hurt at birth? How come Black and Ethnic minority babies suffer most? Why do poor areas have worse outcomes than wealthy areas? Why is infant mortality rising? (The infant mortality rate is the number of children that die under one year of age in a given year, per 1,000 live births. The neonatal mortality rate is the number of children that die under 28 days of age in a given year, per 1,000 live births. These are both common measures of health care quality, but they are also influenced by social, economic and environmental factors). Are there fundamental problems with core policy documents like the maternity review “Better births”? These are painful questions.

    Our campaign wants real improvements for mothers and babies. This posting is not intended as a clinical paper, it is a discussion amongst activists and concerned citizens about where the problems lie. A key set of participants in this discussion are mothers who have given birth, including those who have lost babies, grandmothers and other birth partners, and women who could not conceive.

    Our campaign published our Maternity Manifesto during the election but though well shared on Facebook, it did not get into any parties’ manifesto.

    We also called a national meeting on issues in maternity care.

    What then are the factors that result in UK outcomes at birth worse than other advanced countries?

    The answers include shortage of NHS funding, staffing shortages, poor management in some hospitals, staff in fear of speaking out, some policies and procedures, disrespect towards the women carrying the baby, and, as cited in the East Kent enquiry, a lack of practical understanding by staff and by mums of the need to “count the kicks” in the latter part of pregnancy. The introduction of charges for migrant women has also caused deaths. NHS material seems to centre the cause on mothers who smoke, or who are overweight. (Now smoking in pregnancy is plain stupid, it really is, and most mums would not do so if they were not addicted. Don’t do it!). However, other countries, Greece for example, who smoke more, have better outcomes in pregnancy than does the UK. Wider problems like obesity and diabetes, and even women giving birth older, are mentioned in the literature about this. Again, the age of the mother as a factor, but this is only partly true. Giving birth older is often safer than giving birth too young. Globally it is most often young girls who die in childbirth.

    Answers may lie in the financially and emotionally vulnerable place that pregnant women occupy in our society, including poverty, violence and stress. Poverty and inequality are factors in infant mortality; “The sustained and unprecedented rise in infant mortality in England from 2014 to 2017 was not experienced evenly across the population. In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100 000 live births per year (95% CI 6 to 42), relative to the previous trend. There was no significant change from the pre-existing trend in the most affluent local authorities. As a result, inequalities in infant mortality increased, with the gap between the most and the least deprived local authority areas widening by 52 deaths per 100 000 births (95% CI 36 to 68). Overall from 2014 to 2017, there were a total of 572 excess infant deaths (95% CI 200 to 944) compared with what would have been expected based on historical trends. We estimated that each 1% increase in child poverty was significantly associated with an extra 5.8 infant deaths per 100 000 live births (95% CI 2.4 to 9.2). The findings suggest that about a third of the increases in infant mortality between 2014 and 2017 can be attributed to rising child poverty (172 deaths, 95% CI 74 to 266).” (Our bold for emphasis).

    The UK is a rich advanced country, with a long history of universal healthcare but we have rising infant mortality. “Rising infant mortality is unusual in high-income countries, and international data show that infant mortality has continued to decline in most rich countries in recent years” and “In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100,000 live births per year, relative to the previous trend“.

    Poverty is not the sole cause of high Infant Mortality though, Cuba has good outcomes equal to the UK for infant mortality. Cuba is very poor indeed and the UK is one of the wealthiest economies (sadly Cuba does less well on maternal deaths).  

    Research shows out of 700,000 births a year in England and Wales, around 5,000 babies are stillborn or die before they are a month old”. 5,000 babies each year. There have been major news stories about baby deaths in many hospitals, notably in ShropshireEast Kent and Morecombe Bay.

    Maternal deaths. The UK is not in the top ten countries with the lowest infant mortality rate, neither is it the safest place to give birth. In 2015-17“209 women died during or up to six weeks after pregnancy, from causes associated with their pregnancy, among 2,280,451 women giving birth in the UK. 9.2 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy.” In 2016 The UK ranked 24th in the world in Save the Children’s Mothers’ Index and Country Ranking Norway, Finland, Iceland, Denmark, Sweden, Netherlands, Spain, Germany, Australia, Belgium, Austria, Italy, Switzerland, Singapore, Slovenia, Portugal, New Zealand, Israel, Greece, Canada, Luxembourg, Ireland, and France, all did better than the UK. The situation in some other countries is massively worse than here but that is no excuse. But these baby and mothers’ deaths must stop. We cannot sit back and let these deaths continue.

    Let’s be clear, the situation for women in pregnancy and childbirth is massively better than before the NHS, and is head and shoulders better than in the USA today. But maternal mortality is an issue here in the UK, and a huge issue in poorer countries, especially where women give birth without a trained professional being in attendance. Quite rightly professionals and campaigners in the UK participate in international endeavours to improve this situation. The NHS should be training and sending midwives to those countries, instead, it is recruiting midwives from poorer countries. In Europe we have cuts in healthcare through Austerity; in the global south, the same concept of cutting public services to the bone is called Restructuring.

    Why is the UK, a rich country with (almost) universal health care not doing better by its mothers and babies? Look at just this case and see the problems in the provision of maternity care;

    Archie Batten

    Archie Batten died on 1 September 2019, shortly after birth.

    When his mother called the hospital to say she was in labour, she was told the QEQM maternity unit was closed and she should drive herself to the trust’s other hospital, the William Harvey in Ashford, about 38 miles away.

    This was not feasible and midwives were sent to her home but struggled to deliver the baby and she was transferred by ambulance to QEQM where her son died. Archie’s inquest is scheduled for March. (BBC).

    We know that temporarily “closing” maternity units because they are full is a common occurrence. Women then have to go to a different hospital. Induction of labour can be halted because the unit is full. It is not a pleasant situation for mothers. Some maternity units have closed permanently, meaning mothers have to travel further for treatment, at a time when the ambulance service is under great strain (though being in labour is not considered an emergency for the ambulance service!).

    Shortage of Midwives and consequent overwork for the existing staff. The UK has a shortage of three thousand five hundred midwives. The midwife workforce is skewed towards older midwives who will retire soon.

    Gill Walton, general secretary and chief executive of the Royal College of Midwives said “We know trusts are facing huge pressures to save money demanded by the government, but this cannot be at the expense of safety. We remain 3,500 midwives short in England and if some maternity units regularly have to close their doors it suggests there is an underlying problem around capacity staffing levels.

    Training midwives is not just about recruiting new starters to university courses. There need to be sufficient training places in the Hospitals who are already working flat out, leaving little time for mentoring of students, as well as places in the Universities. Alison Edwards, senior lecturer in midwifery at Birmingham City University, who says: ‘It isn’t as simple as recruiting thousands more students as this requires the infrastructure to support it.

    ‘You need more tutors, more on-site resources and, perhaps more importantly, more mentors and capacity in placement areas – which is currently under immense strain.’ 

    One student midwife wrote about her experiences in this letter, where she described very hard work without either pay or good quality mentoring.

    The government and the NHS call for Continuity Care from Midwives. This means the same midwife or small team of midwives cares for the mother through her pregnancy, birth and postnatal period. We too believe this would be wonderful if it were possible. It is however impossible with the existing ratio of midwives to mothers. Providing continuity of care to the most vulnerable mothers is a good step. NICE have reduced this to the idea of each woman having a named midwife. One to One a private midwife company claimed to provide this but was unable to continue trading, and went bust leaving the NHS to pick up the pieces.

    Nationally the NHS is underfunded and looks set to continue so. Much of the problem comes from a long period of underfunding. We spend less than 9.8 per cent of GDP on health. Switzerland, Germany, France, Sweden, Japan, Canada, Denmark. Belgium Austria Norway and the Netherlands all spend more. That places the UK 13th in the list of high spenders on health care. The US spends 16.9 %. (although a lot of that money is diverted from patient care to the big corporations and insurance companies). The NHS was the most cost-efficient health care service in the world.

    Underfunding causes staff shortages. Some errors at birth come from staff being overworked and making mistakes.

    Some, our campaign believes, flow from fundamental flaws in government policy such as in the Maternity Review, where the pressure is on staff not to intervene in labour.

     Listen to the Mother. Some of the deaths are from women not being heeded in pregnancy and childbirth. This is backed up in reports from mothers, including some quoted in the big reviews mentioned above. However, overworked and tired staff who know labour like the back of their hand can easily stop heeding an inexperienced mother.

    Poverty kills mothers and babies. As we said above, some deaths, poor baby health, and injuries come from growing maternal poverty and ill-health. Low-income families find it hard to afford good food. Food poverty affects a staggering number of children. The charity UNICEF estimates that “2.5m British children, or 19%, now live in food-insecure households. This means that there are times when their family doesn’t have enough money to acquire enough food, or they cannot buy the full variety of foods needed for a healthy diet. In addition, 10% of these children are also classified as living in severe food insecurity (the European average is 4%) and as a result, are set to experience adverse health.”

    Studies show that;

    The Independent inquiry into inequalities in health (Acheson 1998) found that a child’s long term health was related to the nutrition and physique of his/her mother. Infants whose mothers were obese had a greater risk of subsequent coronary heart disease. Low birth weight (under 2500 g) was associated with increased risk of death in infancy and with increased risk of coronary heart disease, diabetes and hypertension in later life. Accordingly, the Inquiry recommended, ‘improving the health and nutrition of women of childbearing age and their children, with priority given to the elimination of food poverty and the reduction of obesity’. (NICE )

    A significant number of deaths of new mothers come from mental health issues that spiral out of control. Some of these will be newly developed conditions and some existing conditions made worse by pregnancy and childbirth. Mothers family and professionals must all be on the alert and intervene early. There are good ways to treat mental health in pregnancy.

    Reducing the social and economic stresses around pregnancy would also help reduce the deaths and suffering

    When Birth goes wrong it can be a dreadful experience for everyone involved. In most cases, the panic button brings in a well-drilled team of experts who can solve nearly every problem and do it calmly. At other times, it is dreadful, as described in the coverage of the birth and death of baby Harry Richford. Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital in Margate in 2017 but died a week later. https://www.bbc.co.uk/news/uk-england-kent-51097200

    Sands, the baby death charity explains that there are many causes of babies dying before birth. Crucially important is that mothers are heeded when they are concerned and that everyone Counts the Kicks

     

    Maternity is not the only area of the NHS that suffers. There have been serious mistakes in NHS planning including closing far too many beds. The NHS closed 17,000 beds and now is working beyond safe bed occupancy. There are 100,000 staff vacancies. Waiting times in A and E are dreadful, as are waiting times for cancer treatment. NHS managers and the Government have taken the NHS far from the Bevan model of healthcare (for history read this).

    Press coverage. How does the press cover the NHS, and baby deaths? There are very real problems in the NHS and maternity care but the coverage in the press of these problems seems to switch on and off in strange ways, often to suit Conservative Party political requirements. The NHS and the Government are masters of propaganda and news manipulation. The public needs to learn to judge the news and to look both for actual problems and look out for bullshit and manipulation. Why was news of the arrest of the nurse from the Countess of Chester hospital headlines on the 70th Anniversary of the NHS? Why was the news of the understaffing there not given similar nationwide publicity? Why have we heard little or nothing since?

    If the government can switch the blame to the professionals in the NHS (but not their mates the high admin of the NHS), then they seem to be happy to publicise the problems. In other cases, problems are swept under the carpet.

    Professionals expect to (and do) take responsibility for their own actions. Mistakes will be made. It is impossible to go through life without some mistakes. When we are dealing with life and death mistakes can be catastrophic, even where there is no ill intent.

    Malicious action is rare.   There are the terrible cases of serial murderer Harold Shipman, and the convicted surgeon Ian Paterson who falsely told women, they had breast cancer and operated on them unnecessarily. The hierarchical system in the NHS and the lack of regulation in private hospital, which was described as “dysfunctional at almost every level” allowed that harmWe have not found such a case in maternity.

    Unintentional bad practice, however, has also harmed babies. No one went to work intending to harm in the events publicised in the Morecombe Bay Enquiry into the deaths of 11 babies and one mother. It was said that “The prime responsibility for ensuring the safety of clinical services rests with the clinicians who provide them, and those associated with the unit failed to discharge this duty over a prolonged period. The prime responsibility for ensuring that they provide safe services and that the warning signs of departure from standards are picked up and acted upon lies with the Trust, the body statutorily responsible for those services.”

    The Enquiry described what happens like this “In the maternity services at Furness General Hospital, this ‘drift’ involved a particularly dangerous combination of declining clinical skills and knowledge, a drive to achieve normal childbirth ‘whatever the cost’ and a reckless approach to detecting and managing mothers and babies at higher risk.”

    The Furness General Hospital was pushing for Foundation Trust status at the time and was not exercising the necessary supervision.

    “Maternity care is almost unique amongst NHS services: the majority of those using it are not ill but going through a sequence of normal physiological changes that usually culminate in two healthy individuals. In consequence, the safety of maternity care depends crucially on maintaining vigilance for early warning of any departure from normality and on taking the right, timely action when it is detected. The corollary is that, if those standards are not met, it may be some time before one or more adverse events occur; given their relative scarcity in maternity care, it is vital that every such occurrence is examined to see why it happened.

    So, many factors come into play in such incidents of harm to mother and baby. Professionals too can be emotionally wrecked by tragedy.

    Huge personal and professional lessons can be learned from a detailed review of cases where mistakes are made. There is a whole literature about learning from mistakes. The worst such incidents are referred to as Never Events. This is just one article about such errors but there is a whole field of research devoted to it. Serious Mistake Reviews often happen at the end of shifts, and in the worst cases, may lead to long public enquiries.

    NHS as a research organisation One of the great virtues of the NHS is the research base it offers professionals. What happens in the NHS which covers 62 million people is studied, evaluated, and researched. This is invaluable to staff and above all to patients. Sadly this research is also of interest to big business especially to those who sell health insurance and to the big corporations who have their ‘snouts’ in the NHS ‘trough’. Research for the common good is clearly different from research to make money. We see that regularly in big pharma. Cheap effective medicines do not make money for the companies. Yet the government is giving away our medical data to companies to make a profit.

    There are also “errors” that happen when everyone is following accepted procedures and protocols; “untoward events, complications, and mishaps that resulted from acceptable diagnostic or therapeutic practice”. Procedures within the NHS can be robust and well researched, and problems still occur.

    https://www.mamaacademy.org.uk/news/mbrrace-saving-lives-improving-mothers-care-2019/

    Research matters. Only by studying outcomes can these errors be revealed. A classic example is the once customary practice of episiotomy, cutting a woman to prevent tears to the perineal skin in childbirth, which is now no longer used except in an emergency. Research both formal and informal changed that practice. As another example of such research, Liverpool Women’s hospital has been involved in research about the benefits of leaving the baby attached by the cord if they are born unwell. NHS staff and other health professionals, academics and pressure groups are working hard to improve outcomes for mothers and babies. Each mothers death is reviewed in the MBRRACE-UK report

    https://mamadoc.co.uk/the-maternal-mortality-report-we-should-all-learn-from/

    Never again. The tragedy of the death of a mother and or baby is felt by that whole extended family. Most families want to know it will never happen again. Cover-ups and lies mean it will happen again, so brutal honesty is needed.

     

    The aftermath of medical treatment or neglect which causes real harm is complex. Whether the outcome is death, life long impairment, or long term physical and mental health issues, these are very significant events for all concerned.

    Campaigners in Liverpool campaign for SEN funding to be returned. 2019

    If a baby is born with life-changing impairments, the baby is left facing catastrophic difficulties and the mother and family can face major heartbreak and hardship. The huge love we have for our kids (may it long continue), whatever their issues, does not prevent the financial, housing and employment issues families with disabled children face. Nor does it guarantee the best educational opportunities, SEN is being battered by cuts. but parents and teachers are fighting back.

     

    The cost of financial “compensation” from an injury to a newborn is huge because it is life long. The cost of this “compensation” used to be carried by the government but the system changed to make hospitals “buy” insurance from a government body which is set up like an insurance company. The cost to the hospital is charged on the basis or earlier claims, like car insurance. Obstetrics make the highest claims of any section of the NHS.

    Liverpool Women’s Hospital had a huge case (not about babies) some years ago, arising from a surgeon who left many women damaged after incontinence operations. Their total bill, over 5 years, according to the Echo, was £58.8 million. “The NHS trust has been forced to pay out £58.8m in the last five years for both recent and historic negligence cases.

    The limited work we do, as a campaign, in holding the hospital to account, leads us to believe lessons have been learned by the hospital. However, in every hospital, there are pressures which could lead to problems. These pressures include financial and organisational, problems of management ethos, and the potential for bullying, the distrust by the staff of their management, and disrespect for whistleblowers.

    The NHS has gone through years of reorganisation after reorganisation. In that time the financial and government pressure has been to complete the re-organisation, or face catastrophic consequences so very many hours of admin and senior doctor time has been wasted on this process. That time could have been focussing on saving babies.

    At STP and national level, there are other problems. The NHS is intensely political. There are deep structural problems. (We believe the NHS should return to the Bevan Model of health care)

    The NHS is not only deprived of adequate funding, but it has also been forced to implement many market-based changes, including the internal market, outsourcing and commissions of services to for-profit companies. These market-based structures are expensive.

    The NHS has also seen dire staff shortages resulting from stupid decisions like removing bursaries, not training enough doctors and the hostile environment to migrant staff.

    There are moral and financial issues in all cases of such errors. The hurt to the babies is our priority.

    Baby deaths and severe injury at birth have complex roots. Though what happens in the hospital is crucial, it is not just what happens in the hospitals that matter. The stress, poverty and anxiety many mothers endure during pregnancy do sometimes affect the outcomes for the child. Many women are still sacked for being pregnant but families can rarely cope with just one wage (do fight back against sacking pregnant women!). See Maternity Action for details. Both mums and midwives can call Maternity Action for advice.

    Low pay or the dreaded universal credit can make food heating and rent all too expensive. This can lead to food poverty. Women do not yet have real equal pay but mothers have the worst pay of all  Benefits are no longer allowed for a third child. even though most claimants are working. Whether parents are working or not, every child has a right to food and shelter, be they first or 10th child. The child gets no choice!

    Not every pregnant woman is in a stable caring relationship. Housing, especially private renting, becomes more difficult when women are pregnant. Who can forget the story of the homeless woman giving birth to twins in the street? Pregnancy is often the time when domestic violence is inflicted on a woman but it is the time when women are least able to walk away. Poverty kills babies too.

    Please join us in campaigning for better outcomes for all mothers and babies in the NHS and across the globe. We want this to start a discussion, so please send us your views. and information

     

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    This article was first published in the Camden New Journal under the title, Brexit, and spectre of NHS US sell-off, on 16 May 2019.

    There is much talk at the moment about the prospect of Brexit resulting in a trade deal with the US which will sell off our NHS to American private healthcare providers.

    This fear has also been expressed by Shadow Health Secretary Jonathan Ashworth. [1] But it is critical to understand this “sell-off deal” has been under way for a long time and is fast gaining momentum, argue Susanna Mitchell and Roy Trevelion.

     

    The driver of the “sell-off deal” is Simon Stevens, who in 2014 was appointed head of NHS England, the body that controls all NHS spending. Before this, Stevens had been vice-president and CEO of the mammoth American healthcare corporation the UnitedHealth Group.

    Stevens has proceeded to “Americanise” the service through his subsequent NHS policy, based on a privatisation strategy he had outlined at the World Economic Forum at Davos in 2012. [2]

    From first to last, his NHS policy – the Five Year Forward View, the Sustainability and Transformation Plans and Accountable Care Organisations (renamed Integrated Care Programmes) that back it up, and now the 10-year Long Term Plan – have worked to import the US model into the UK.

    Unsurprisingly, the UnitedHealth Group will make major gains from this transformation. It is now the largest healthcare company in the world, with a 2018 revenue of $226.2 billion. It has many secondary companies that serve more than a hundred-million people globally. [3]

    Over the years it has been prosecuted for fraud and bad faith practices. This included limiting insurance payments to doctors, and not stating its true financial results in reports to shareholders. [4] [5]

    One of its fastest growing subsidiaries is Optum (formerly UnitedHealth UK). This is a leading information technology- enabled health services business. In February 2015, it was one of the commercial organisations approved by NHS England as “Lead Providers” to carry out the financial work of GPs.

    It is now firmly positioned in the system and ready to take away more public money. [6]

    The healthcare system in the United States is hugely more costly, and outstandingly less effective than that in the UK. In terms of funding and wellbeing, there is no rational argument for imposing it on our NHS. The only benefit it brings is increased profits for shareholders in the commercial healthcare sector.

    To take three examples, first comparing cost:

    On average, other wealthy developed countries spend about half as much per person on health as the US – in the US $10,224 compared to $4,246 in the UK. In 2017 the US federal government spent 7.9 per cent of GDP directly or indirectly on healthcare; however in total, taking into account private expenditure, the US spent a vast $3.5trillion or 18 per cent of GDP. This private sector spending is triple that of comparable countries. [7] [8]  This structure excludes many citizens from affordable health­care. Appallingly, one in four adults skipped a medical treatment in 2017 due to an inability to pay. [9]

    Secondly, from the point of view of efficacy and wellbeing, statistics are also devastating. The US has the lowest life expectancy at birth among comparable countries (US 78.6, UK 81.2). Statistics show that life expectancy for both men and women has increased more slowly in the US. It comes 12th in the global life expectancy table. [10]

    Thirdly, the US maternal mortality rate is truly shocking. It stands at 26.4 per 100,000 live births, the worst among all developed countries. [11]

    In the UK the rate stands at 9.2 per 100,000. [12] [13]

    Deaths for African-American women are three to four times higher than for white women. [14]

    The infant mortality rate is also worse. The US rate is 5.79 deaths per 1,000 live births. [15]  The UK rate is 3.8 deaths per 1,000 live births. [16]

    It is clear that if we follow the American model of healthcare it can only reduce wellbeing in the UK. Simon Stevens’ “sell-off deal” simply increases the wealth of global corporations (such as the Mayo Clinic, which has recently opened in London [17]).

    It is time that this fact was “called out” loudly and clearly. All possible measures must be taken to prevent the continuing imposition of this ineffec­tive and costly system.

    Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.
    References, some links, live at the time of writing, may not have been maintained:
    [1] BBC Question Time 25.04.2019  at 47.21 ff  https://www.bbc.co.uk/iplayer/episode/m0004hkk/question-time-2019-25042019 .
    [2] https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/
    [3] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [4] https://www.sec.gov/news/press/2008/2008-302.htm
    [5] https://law.freeadvice.com/insurance_law/insurers_bad_faith/unitedhealth-pays-400-million-in-bad-faith-claim.htm
    [6] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
    [7] https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
    [8] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
    [9] https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
    [10] https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-le_the-u-s-has-the-lowest-life-expectancy-at-birth-among-comparable-countries_2019
    [11] https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1560004210914
    [12] https://vizhub.healthdata.org/sdg/
    [13] http://digg.com/2017/uk-birth-us-safety-comparison
    [14] https://www.huffingtonpost.co.uk/entry/elizabeth-warren-black-maternal-mortality_n_5cc0e93fe4b0ad77ff7f717b?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACQmWXh6QTnSJI5sjLN1KEdQCuSnVb__LEQLJAyEiK2PZwqnVABYxo500JrU24NHWCooflTZAia50H4OJ-YzSPMUqXyGODWHMGcBXUxhfVY-fau-ViM-Ly9n32SQ1vXD-SGhWXohZRVo2givDSEbM1D3TVs38R5MjmfY_5rGZXuP&guccounter=2
    [15] https://www.cdc.gov/nchs/nvss/deaths.htm
    [16]https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2016
    [17] https://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnershiphttps://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnership.

     

     

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    Mean societies produce mean people

    Babies haven’t changed much for millennia. Give or take a few enzymes this perfectly designed little bundle of desires and interests has not needed to evolve much. Of all primates, the human is the most immature at birth, after which brain growth accelerates and is ‘wired’ according to the kinds of experience the infant has. Provided there are a few familiar and affectionate people there to care continuously for him or her, baby will be fine. If not, evolution has taken care of that too. You live in a cruel world and treat him roughly? He will develop into a compulsively self-reliant and ruthless individual with little concern for others. Mean societies produce mean people. Through attentive care in the early years we may hope to produce thoughtful, curious and confident young people but our social arrangements are essentially hostile and competitive. Having a baby is regarded as an expensive undertaking rather than as a contribution to the future of society.

    Encouraged by successive governments our world is geared to markets. “It’s the economy, stupid” means you can’t do anything without considering the immediate cost. The more this idea takes hold the stupider we become. The current government’s dedication to continuous welfare cuts hits children disproportionately. Neoliberalism is the enemy of children.

    Evolutionary imperatives

    This is not the environment in which humans evolved. An infant in a hunter-gatherer band – the way we all lived for 99% of our time on the planet – would have spent many hours being held, and not only by the mother. “Infants with several attachment figures grow up better able to integrate multiple mental perspectives”. We are programmed from the start to seek out third positions, to acquire the “capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting on ourselves whilst being ourselves.”

    Systematic comparisons between sedentary foraging and farming people living now in neighbouring parts of the Congo basin show how much more egalitarian the foragers are. Men and women see themselves as equal. They hold and converse with their tiny children more intensively, they let the baby decide when to wean and teach them to share from an early age. Violence is rare, though teasing is common. Such children are more socialised than in the west and at the same time protected from catastrophe in the event of the mother’s death. Amongst the farmers, in contrast, “corporal punishment is not an uncommon response for young children who do not listen to or respect their parents or older siblings”.

    In the modern world little public money is available for perinatal services, parental leave, for quality child care and universal education, affordable and secure homes, healthy food, subsidised transport and energy, sports fields, swimming pools, libraries, parks and playgrounds that make rearing children and adolescents more manageable and more successful. Tax, like children, is seen as a ‘burden’. So governments of all parties sign up to reducing it, yet still find money for bank bailouts and unsustainable wars. Whether local or national, tax should be a contribution to the common good, an instrument of social justice. It is collected from citizens, for citizens. In the current climate this equation is neither acknowledged nor understood. Yet something has been understood that was not clear before. There is a greater recognition that early intervention is a good idea: “the brain can be sculpted by experience”; the sooner the better.

    Start at the beginning

    When a woman becomes pregnant her physical and mental states impact on her child. From conception onwards the health and resilience of children – and the adults they will become – is compromised by stress, diet, maternal weight, drugs, genes and insecurity in their parents. Besides the impact on the mother herself, anxiety and depression during pregnancy and after it have significant long term effects on the child’s physical and mental health – particularly on boys – generating huge social costs. Pregnancy is a dangerous time for some women. The most socially deprived mothers are more likely to have very premature births or perinatal death. Low birthweight leads to poor outcomes; early intervention can reduce that.

    Elegant research shows how already by a few months old babies are engaged in triadic relationships; they are affected by tensions between the adults caring for them. When caregivers are uncooperative infants may be “enlisted to serve the parents’ problematic relationship rather than to develop their own social competence”. Children will more likely thrive if caregivers – parents and grandparents, childminders, daycare and children’s centre staff, nursery teachers – get on with one another, like a good team. “Communication between parents and care providers is crucial to the quality of care.”

    The routine availability and presence of health visitors and other staff supporting new parents and of Sure Start centres for children and families create the conditions for reliable care of children. In a context of skilled early years provision, infants whose parents are paid to spend time with them in the early months are less likely to die. “A ten week extension in paid leave is predicted to decrease post neonatal mortality rates by 4.1%”. This remarkable finding represents just the tip of an iceberg of developmental damage and pathology, modifiable by intensive early support for families.

    Better training and pay for early years staff improves outcomes and reduces turnover. UK needs to learn from continental Europe the tradition of pedagogic professions: proper pay, status and training for the job, particularly when the families most in need are hard to engage. Looking after small children is demanding and stressful, requiring continuous professional development such as reflective discussion groups in which colleagues both support and learn from each other. Work with young families is a professional skill.

    Inequality undermines trust

    A collaborative partnership between caregivers does not in itself cost money, but is undermined by social disintegration, the most poisonous source of which is rising inequality. In Britain this has reached levels not seen since the 1920s. The much maligned 1970s was actually the most egalitarian in our history. Consider this: one index of social health is the number of boys born in comparison to girls. Because the male fetus is more vulnerable to maternal stress, women produce fewer boys when times are hard. (For example there is a fall in the ratio of boys to girls a few months after disasters such as massive floods or earthquakes, or the terrorist attack on 9/11). In England and Wales the highest ratio of boys to girls occurred in 1975. In terms of contented mothers it was the best of times.

    Inequality creates stress in parents who can’t keep up, and anxiety in the better off who fear sliding down. No one is comfortable on a steep slope. It makes all of us less trusting and more averse to communal commitments, such as respecting our neighbours and paying tax. Infant mortality, mental illness, drug abuse, dropping out of education, rates of imprisonment, obesity, teenage births and violence are all higher in unequal countries like ours.

    Though often disappointed, our ancient baby is born to expect some kind – a rather conservative kind – of socialism. What will today’s infants be talking about in 2050? If they know any history they will regret lost opportunities; our collective loss of vision that led to wasted generations. The success of the post war consensus was due in part to the fact that it lasted longer than one or two parliamentary terms, so that children could grow up, get educated and housed, find partners, get work and free healthcare without overwhelming instability or despair. The needs of a baby born today are precisely what they were for one born in the 1950s, or 50,000 years ago. New knowledge of infant development is catching up with evolved wisdom, yet we continue to ignore both, and build bigger obstacles to secure attachments.

     

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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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    The case for a new Beveridge Report

    One of the last Labour Government’s real successes was to preside over an increase in life expectancy. In addition, the gap in life expectancy between the rich and poor decreased. Fast forward nearly 8 years, to March 2018 the Office for National Statistics published data showing that under Tory austerity the gap in life expectancy had widened. For women, the gap is the largest since the 1920s.

    There is overwhelming evidence that these inequalities are not inevitable. They are socially reproduced. They can be changed. And that should give us all hope. But it needs political will to tackle them, not the soundbites of this Government.

    In 2015, the International Monetary Fund stated that ‘widening income inequalities is the most defining challenge of our time’. Forty years ago, 5% of income in the UK went to the highest 1% of earners. Today it is 15%. According to the latest Sunday Times Rich List, the richest 1000 people in our society saw their wealth increase by 16% in the last year alone. This trend of increasing income inequalities has occurred in most high income countries, but some less than others.

    Like Nobel economist Joseph Stiglitz’s, the IMF’s analysis showed that inequalities are a drag on growth and can also make growth more volatile. It showed that raising the income share of the poorest 20% of the population increases growth by as much as 0.38% over five years. In contrast, increasing the income share of the richest 20% by 1% decreases it by 0.08%.

    The Organisation of Economic Co-operation and Development has also rejected ‘trickle down’ economics, so popular with Margaret Thatcher and her supporters, as the means of spreading income from the rich to the poor.

    In spite of promises to tackle these ‘burning injustices’, according to the Equality Trust, Britain’s top bosses are paid, on average, 165 times more than a nurse, 140 times more than a teacher and 312 times more than a care worker. Indeed it would take a typical UK worker 160 years to rake in the average annual amount handed to a FTSE 100 boss.

    The recent Equalities and Human Rights Commission report has revealed that the poorest tenth of households will on average lose about 10% of their income by 2022 – equivalent to £1 in every £8 of net income. This reflects other distributional analyses for example from the Institute of Fiscal Studies.

    Reducing the gap between rich and poor is not just good for the economy. As evidence from The Spirit Level shows, life expectancy increases, as well as educational attainment, social mobility, trust and more. Fairer more equal societies benefit everyone.

    In acknowledging the income inequalities that exist in the UK and the harm that this is doing to society as a whole, the question is what drives them and how to tackle them.

    As Labour committed to in last year’s manifesto, we need changes to economic policy to address the unfair tax burden and poverty pay. But we also need to radically transform our social security system so that, for example, 8 million people currently in low paid jobs are not left living in poverty while they wait for pay improvements, and neither are their children. And if you become sick or disabled you should not be twice as likely to live in poverty as non-disabled people, as 4 million disabled people are now. Similarly, the state pension age for men and women shouldn’t be quietly pushed back, leaving increasingly frail, elderly people unable to work, subjecting them to live in poverty.

    The 1942 Beveridge Report was the basis for a new welfare state set up after the Second World War, including the establishment of the NHS in 1948 and the expansion of social security. It was heralded as a revolutionary system that would provide ‘income security’ for its citizens ‘as part of a comprehensive policy of social progress’.

    Since 2010, we have seen social security spending cut by nearly £34bn, with another £12bn planned by 2022. Spending on the NHS is barely keeping pace with inflation, and is falling behind countries like Germany, France, the Netherlands, Denmark and Austria.

    We need a new Beveridge report for the 21st Century, defining a new social contract with the British people, addressing the poverty, inequalities and indignity millions of people, young and old, are enduring; bringing hope to a new generation as it did 70 years ago.

    Of course these reforms need to be coupled with reforms to the current dysfunctional and increasingly precarious labour market as part of a coherent and comprehensive industrial strategy. Labour’s plans for a national education service that is not just about preparing you for work but is enabling you to get the most out of life, are also essential to tackle the structural issues that drive these income inequalities.

    In addition to inequalities in income, inequalities in wealth, with land and property being the largest real asset, also need addressing. In 2002 it was estimated that 69% of the land in the UK was owned by 0.6% of the population. In the six years to 2011 the number of landholdings reduced by 10% but the size of these holdings had increased by 12%. So even fewer people own even more land.

    Many in housing policy emphasise that if we’re to solve the housing crisis in addition to building more homes, we need to tackle the cost and availability of land and address the volatility in the market. With average house prices in the UK in 2017 at over £226,000 (over £496,000 in London), the Nationwide Building Society has estimated that it would take 8 to 10 years for people on average incomes to save the 20% deposit needed to buy a house and even longer for someone on a low income. Which means wealth inequalities are increasing even more.

    And finally there’s inequalities in power. This is often the neglected inequality but is central to who we are as human beings. Power is complex. It is about having influence, control, even authority. We usually think of this as associated with having money or ‘corporate power’. But it is also about position and status. In who makes decisions and how. Whether corporate or other unaccountable, ruling elites, the dangers are clear. Elites exclude and marginalise, enabling prejudice and discrimination to thrive, and trust in others, in difference to suffer as a consequence.

    Inequalities are not inevitable but to tackle them in all their forms takes commitment, it takes courage and it takes leadership.

    First published on Debbie’s website 

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