Innocent, sick children locked in police cells – why are we not prioritising children in need?

The most shocking headline this weekend was surely that young children are being locked up in police cells when they are suspected of being mentally ill at the rate of nearly one child a day. Freedom of Information requests revealed that 347 children were detained under the Mental Health Act last year; children who the police or ambulance service thought were so mentally disturbed that they needed to be taken to a place of safety and assessed by a psychiatrist. The trouble was that there simply weren’t enough safe places to which children could be taken, so day after day an acutely distressed, vulnerable and sick child ended up in a police cell where they were totally isolated, instead of being in the reassuring presence of a qualified professional in supportive surroundings.

As with so many other illnesses, early assessment in mental illness is crucial to finding both the right treatment and for a more rapid rate of recovery. Imagine your child having a suspected appendicitis, being distraught in immense pain. The paramedic then tells you that as the local hospital’s abdominal surgeons are on an “away day” your child will be kept safe in a police cell in the meantime! (In one of the child cases above where they ended up in a police cell, mental health professionals were on an away day with no cover arranged at the local hospital). It’s a ludicrous comparison and scenario I will admit, such delays in assessment are unthinkable. However mental illness is just as important as physical; in fact it is in many ways unhelpful to separate the two as there are usually mental illness symptoms in physical sickness and physical symptoms in mental illness.

These are not children who have done anything wrong or criminal, they simply happen to be one of the 10% who at some point in their childhood suffer with mental illness. Even with a severe episode of ‘psychosis’ where someone loses touch with reality, for 25% of people it’s a one-off event.  Psychosis occurs in 3% of the population, making it more common than other conditions such as diabetes. Three-quarters of mental illness develops before we reach 25 years of age and overall mental illness accounts for about 23% of all disease (compared to cancer at 15% and heart disease at 16%) but only about 11% of the NHS budget is spent on mental health.

What this research highlights again today is that we are not resourcing mental health properly, and children’s services in particular are failing some of the most needy. The health minister Norman Lamb spoke on the radio yesterday about picking up with the Home Office on this issue, but he was getting mixed up with the provision of mental health services for  young offenders (also woefully inadequate). Mental health services for law-abiding young people are a joint responsibility for the Department of Health and the Department of Communities and Local Government, and although the health budget has been protected, cuts to Local Authority budgets have resulted in 53% of Councils cutting their mental health provision in the last year.

We have plenty of research that helps us predict the demand for mental healthcare. We also know that across the board, demand on the health budget is growing. While no politician will admit that we don’t have enough tax revenues to fund healthcare properly, and decisions on what we prioritise in the NHS are therefore taken by stealthy rationing, tragic occurrences such as the incarceration of highly needy children will continue. Surely politicians are failing some our most vulnerable children if they will not insist that child mental health is adequately resourced, even if it means that other, optional services are withdrawn? If there is one worthy task the new Police and Crime Commissioners can get straight on with, it is ensuring that no innocent, poorly child ends up in the police cells.

International Development: the chance to leave the world, not just our country, in a better place

On the day when Americans are choosing which direction their country will take over the next four years, I doubt there are many who think that one of the candidates has all the answers. The best politicians are those who have considered the needs of society and want to invest their lives in putting into place policy that they believe will lead to improvement. No one, quite rightly, promises Utopia; but through refining, planning and empowering they aim to leave their country in a better position than that in which they found it.

To argue that any particular policy area isn’t working is conventional; to argue that a whole strategy is wrong and therefore the department should be abolished is bizarre. Imagine if Michael Gove had taken that approach: education is failing so let’s stop funding it! But this is what we regularly hear people proclaiming in the press about the International Development budget. Added to this, apparently we shouldn’t, and can’t afford, to give away money until we have ‘our own house in order’. Does anyone really think that will ever happen? If each of us waited until we felt we could afford to give money away, we’d quickly see every charity in the land fold. Visit a local food bank or talk to a counsellor from Christians Against Poverty and it’s true, many people in Britain are having a really hard time right now, and the correct response should be that those of us in work should be sharing more of what we have. But this is the same principle that means on an international level, we as a country should share some of what we have with those in countries who are desperately needy.

Reading ‘The Ringtone and the Drum’, the new book by Mark Weston, on his travels in the three of the world’s poorest countries, one regains some perspective on how some of the world’s poorest people are trying to cope. He starts in Guinea-Bissau, a country that few have heard of and very few visit. With no infrastructure, no electricity since the state power company ran out of money in 2003 (so even government ministers have to charge their mobiles at internet cafes which have the generators that their ministries lack), no free healthcare, daily survival is a challenge. Along the coast in Sierra Leone, there isn’t even a functioning hospital even if you did have the money to pay for treatment. People walk around covered in grime and dust, not through choice, but through no access to running water. Poverty reduces relationships to transactions: I will only give or share if you give something back. Even little children see their bodies as economic assets and girls expect to sell themselves for money. He ends his journey in Burkino Faso which is at the sharp end of the impact of climate change; heat and famine claim many lives and orphans who survive are increasingly being exploited by Al Qeada.

As Mark says, the “ubiquity of individual tragedy (in West Africa) and your close proximity to it” make it difficult to sustain any shallow detachment. But away from this stark reality, many of us are removed and see foreign aid as something we can’t afford. ‘The Ringtone and the Drum’ reminds us of our affluence and privilege as well as taking us on a fascinating journey through West African history and geography. As with any policy review, our response should not simply be to agree to keep giving aid, but to rigorously review to whom and how are we giving? This is not about the powerful making decisions on behalf of the poor and creating dependency, but understanding that the poor have a huge burden of taking responsibility for everything in their lives, much of which we the wealthy don’t have to e.g. growing our own food. Therefore our aid needs to relieve some of the burden (such as providing education and healthcare) as well as giving people productive assets (such as a cow).

A pound goes a long way in Africa and the Secretary of State Justine Greening is rightly now reviewing how and to what we give. Wise investment and an intelligent approach would not only save lives but transform communities as economists such as MIT Professor Esther Duflo has shown. And by the way, there is an opportunity to hear more about the need as Mark is talking about his book at the School of Oriental and African studies on Wednesday lunchtime.

Dying to talk: why GPs discussing death should not be taboo

Dame Cicely Saunders is ranked alongside Aung San Suu Kyi, Dietrich Bonhoeffer, Martin Luther King and Nelson Mandella in former Prime Minister Gordon Brown’s book ‘Courage: Eight Portraits’. Dame Cicely spent eleven years thinking about how to develop a place where people who knew they were dying of cancer could be looked after with holistic care, before founding St. Christopher’s Hospice in 1967. She knew from her own experiences of grief that medical care wasn’t enough: for people to be treated with dignity at the end of their lives required a co-ordinated approach of pain-relief, psychological and spiritual provision, and recognition that family and friends need to be supported too. She transformed both the approach and attitudes to end-of-life care, initially just for those with cancer but then extended the approach to others too, and her method has been copied world-wide.

So when we hear that GPs have been encouraged to think about which of their patients could be nearing the end of their lives, we should be really pleased. How many stories do we hear of people not getting the support they need when dying, people not being asked where they would like to die, families not being asked about arrangements to provide for their loved one as the end approaches? Apparently 35% of GPs have never initiated a conversation with any of their patients about how they would like to be provided for as they face death. Considering death is such a certainty, isn’t this a ridiculous taboo? GPs are now being encouraged to proactively think through who will need end-of-life care, so that it can be thoughtfully discussed and sensitively planned.

So the last thing we need are sinister stories about ‘death lists’ and that people are being ‘singled out’ as those who are ‘going to die’, and the implication that this is about saving money. This is journalism at its worst: scaremongering, damaging and disingenuous. Some of those who were summoning up the courage to talk to their doctor about their fears and concerns of dying now will not do so, having had the trust in their GP undermined.

Ironically one of my frequent complaints has been that we don’t know which GP’s actually sign up to the National Gold Standards Framework which was designed to ensure the best possible standard of care for those nearing the end of life. As patients we should know what our local GPs offer and when I am elderly or dying or both, I will want to be registered with a practice that has signed up to the Gold Standard. I will want to review how and where I will die. Predicting the timing is an innacurrate science, but at least when death begins to loom, my wishes will have been made known. Polls show that most people want those discussions, with up to 70% wanting to die at home but the majority of us still dying in a hospital, the modern equivalent of the Poorhouse.

I hope all newspapers who have run the scare stories will now run some features on how palliative, hospice and pro-active end-of-life care have enabled people to be treated with dignity in their final months and days. 1% of their readership will die this year (the average annual rate), and it would be a horrific to think that some people may die unsupported because they were too scared to talk to their GP. Dame Cicely would be appalled.

Challenging and changing attitudes are a key legacy of these Games, and reflecting that in healthcare must be a priority

Over the summer a few new national treasures have emerged. One of them is Clare Balding, who having articulated the thrills and spills of the Olympics on the Beeb was then seconded to Channel 4 to continue expressing our joy and pride at the Paralympics. Last night as she rounded up the final programme she reminded us of what should be one of the lasting legacies of the London 2012 games: a legacy of attitude.

We’ve been challenged as a nation. Even before the games began we saw communities across the nation come together in support of Olympic flame bearers and felt our hearts stir. As the games opened we felt national pride at our history of innovation and endurance; as they got underway we experienced kindness and generosity from those involved at a level normally only seen at times of disaster. And as we witnessed paralympians triumphing over disaster, day after day, we were humbled and awestruck.

The legacy of attitude that Clare referred to is up to each one of us. When GK Chesterton answered the question to ‘what is wrong with the world?’ with ‘I am’ he expressed a truism that we must not forget. It is down to each one of us to honour the memory of the games with our own expressions of kindness; our own willingness to get involved; to look for what we can achieve and help others to achieve; to paraphrase another great man, to ask what we can do for our country.

We face many difficult years ahead. We think we know what we are dealing with now, but if the Eurozone falters we could find the economic crisis of today is only the first chapter of austerity. Yet if we start living the legacy now, thinking about what we can do both for ourselves and for our communities, relying less where we can on the State, then we will have an attitude that honours the gamesmakers. Only last week a group of MPs debated community hospitals and how many of them benefit from volunteers, community support and kindness. They called for a review of the ownership models, and one of the most promising is that of mutuals. A mutual set-up involves one or more of a combination of elements of employee ownership, co-ownership, social enterprise and mutuality. The model promotes self-reliance and all the benefits (such a pride, willingness to innovate and stronger community ties) of having a stake in the organisation for which you work or volunteer. Many community hospitals are synonymous with more holistic, compassionate care, have active participation from the locality that they serve and promote and enable independent living. Enabling greater involvement of a community in its own healthcare provision is a sustainable and affirming solution to the challenges we face, not least the reduced tax-take from the decrease in the ratio of working people to the over 70’s which is predicted to fall dramatically from 5.3 to 1 back in 2010 to 3.7 to 1 in 2030.

London 2012 couldn’t have happened at a better time for the nation. It has given us momentum for believing that each of us can do more, encouraging us to care and value caring more, and can make a contribution to our society. This greater confidence is a good thing.

Jeremy Hunt called in to give NHS TLC

The airwaves had gone quiet recently about Andrew Lansley. Whereas before many reckoned that he would be removed as Secretary of State for Health once the new NHS Act was through, increasingly people then wondered who else would want to take on this brief with the complex reorganisation underway, understood by very few outside of the Department of Health.

And of course everyone in politics knew that health was the only job Lansley wanted, and one for which he had waited for over six years. However, Lansley has today been replaced by Jeremy Hunt. The Prime Minister has been kind to Lansley, who is his old boss, and given him an overarching role - Leader of the House - which gives him the job of organising all Commons business, including health, as well as deputising for the Prime Minister when he or his deputy can't be there.

It was probably the only thing that Lansley could take and that the PM could give which still allowed him a high profile, a seat at the Cabinet table and the opportunity to talk about health. Savvy.

Jeremy Hunt had always been the one people mentioned as a replacement for Lansley, but after the Sky semi-scandal the chattering stopped. In public. However, my take on the thinking behind his appointment is this: The PM now wants a safe pair of hands who will spend the next 3 years listening, building relationships, supporting clinicians in their new commissioning roles - who will stop (let's hope) manager bashing, and be a general all-round TLC ambassador for the NHS. He will have the mid-Staffs report to deal with; he will need copious amounts of patience and diplomacy as the new structures emerge; and he will need to bring his commercial wit into play when it comes to sorting out a new payment scheme for medicines and building confidence in the independent sector.

The new health secretary has his work cut out just to deal with the situation as it is, although the rising demands and unsustainable costs mean that devising new income streams, reducing some provision, and supporting radical new ways of delivering care cannot be ignored. Other new ideas would probably be limited to social care and building public confidence post mid-Staffs. No small task, but more about consistency than concepts. 

Interestingly, in his previous role, Hunt oversaw the support for installing super-fast broadband in England, and part of his thinking was to facilitate telehealth. With the increasing ability to skype your GP, have an appointment with a distant consultant though a video monitor, access online medical records, and see a high resolution CT scan on a laptop, this is a radical change that he should get behind. No pressure, but 1.5million NHS employees are now watching Hunt very carefully.

Patients missing appointments - maybe they never needed them?

If someone doesn’t turn up for an appointment there are only a few possible reasons: they died; they forgot; transport failure or they didn’t need the appointment in the first place. The figures for the number of people not turning up for NHS appointments were revealed over the bank holiday weekend – one in ten people don’t attend an appointment totaling 5.5m missed appointments in the last year. This includes appointments people have made for themselves.

BBC local radio also covered yesterday the forthcoming 2020health report on how few people are being given electronic access to their health records (one in 100), despite the evidence showing that patients who take up the service usually have better health.

The common theme here is that NHS remains far too paternalistic, with doctors making many decisions without involving the patient and still regarding intimate details about an individual’s life history (i.e. the patient’s notes) as belonging to the state. Legally notes do still belong to the NHS, but despite the fact we have had the right to see our records for a couple of decades, many professionals still view us as passive recipients of care instead of active participants who should be involved in planning and management. This includes whether we really want an appointment, or just a quick call for reassurance or leaving it to us to decide. I recently sat by a doctor’s desk in a large London teaching hospital as he viewed his PC. He hadn’t looked up when I walked into the room; he’d spoken to either the notes or the screen, and it was only when I said “and I’d like a copy of my test results” that he looked at me. “Why would you want those?” he asked abruptly as if talking to an unreasonable child.

Personal electronic health records will go a long way to enabling us to take more responsibility for our healthcare. More information leads to greater understanding and awareness and can lead to improved health. The proliferation of health apps show that there is a real appetite for information and self-care. The government should be falling over itself to encourage electronic access and approving apps as this will reduce the burden on the NHS and go some way to reducing the 40% (according to GPs) of unnecessary appointments, easing the difficulties experienced by some patients who have found it harder to get an appointment because of their local surgery reducing their opening hours. And if we really are going to have a system that people value and includes rights, responsibilities and redress, then we should be charged the cost of the appointment if we don’t show up (easily done with an electronic system) which will help us decide whether we needed the appointment in the first place!

NHS International: with careful branding this should be part of our growth agenda

It was surprising to hear the government announce the launch of a new initiative yesterday to encourage NHS Trusts to expand abroad (as covered here by Tim Shipman), but only because this is already happening. Back in 2010, Andy Burnham, the then Health Minister launched NHS Global, with the explicit aim of generating income internationally from the NHS brand to be ploughed back into NHS care at home. He could well have been inspired by Moorfields Eye Hospital, where I did some of my training. They launched a satellite hospital in Dubai in 2007. Moorfields brought local doctors over to the UK to train them and they then went back to deliver care under the internationally renowned 'Moorfields' brand.

The fact that Moorfields already had a brand however is key. "NHS Eyecare" (despite the pun) would not have had the same appeal. It will be the major hospitals who will have an opportunity here, often already with an internationally known brand and area of specialty such as Great Ormond Street or the Royal Marsden.The government will have to be careful about overselling the 'NHS' tag, despite the Olympic endorsement. No one is looking forward to the Mid-Staffs inquiry report due out in the Autumn when there will be no getting away from seeing the NHS at it's worst.

There is another key point here - this would not be nearly so appealling for NHS Hospitals if the government hadn't already raised the private income cap. Until the 2012 Health and Social Care Act, NHS hospitals were only allowed a small fraction of their income to come from private sources. The new Act means that up to 49% of an NHS hospital's income can now come from the private sector, which includes private patients, research, support biotchnology start-ups as well as international sources. And before you start to worry - the income has to be spent in the NHS and it is illegal for any NHS patient to have their treatment delayed in preference of a private patient.

This policy has been supported by both the main parties and Labour should be claiming the idea as rightly their own. We should not be obsessed with all NHS income coming from the taxpayer when we know that rationing is happening now and with an ageing population demand will continue to rise. No options should be off the table when it comes to generating new income for the NHS and it is not before time that we exploit our world-class hospital brands to enhance our reputation and potentially attract more business in the UK too. As Andy Burnham pointed out back in 2010, BBC worldwide has been a huge success; added to this our universities, police and fire rescue crews have all contributed internationally and capitalised on their reputations. The healthcare industry is estimated to be worth $4 trillion worldwide. This is surely an ethical opportunity for generating more income for the NHS, exploiting our succesful hospital brands and should be part of our growth agenda.

Cancer is rising but so is indifference

There is a mixed response to today’s report in the Guardian that the number of older people living with cancer will treble by 2040. As cancer is much more prevalent in the elderly and more of us are living longer this isn’t a terribly surprising revelation. However there is a story within this report that is worth more consideration. The biggest increase in cancer will be experienced by women who smoke. At the moment, 319 women out of every 100,000 develop lung cancer; this is set to rise to 813 per 100,000. Most cancers are sporadic and we have no idea what the cause is, but smoking is a no-brainer: every cigarette you smoke raises your risk of developing lung cancer. So my question is this: why the indifference?

I once asked a friend of mine who spent 30 years as a psychiatrist what was the most significant change that he had witnessed during his time of practice. His answer was the “rise of indifference”. People seeming not to care or be concerned, about their habits, about their appearance, about the risks they took. In an age when we have all bemoaned the increasing propensity of government and institutions to be more risk-averse, many individuals seem much more inclined to both live dangerously and expose themselves (often literally when it comes to scant clothing). One reason might be that with a free NHS, people think that whatever they do, if they incur injury there is a service that will treat them and get them back to normal (known as risk-displacement). Whilst the service is free, the numbers show that the NHS can’t work miracles: in 1979 an average of just under 6 men per 100,000 of the population died from alcohol related deaths; by 2003 this had risen to nearly 16 per 100,000 and we know this to be an underestimate as if, for instance, you develop cancer from alcohol consumption, alcohol doesn’t get mentioned on your death certificate.

Maybe the rise is indifference is more deep-seated than risk-displacement however. Seeming not to care can go hand-in-hand with low self-esteem, or a denial of what is important to you in an effort to be part of a crowd, a response to abuse, a reflection of hopelessness or plain selfishness. In any event, it seems to me to be a negative indicator of well-being rather than a positive outcome of freedom, and in this light, maybe the crisis of poor care standards in hospitals or neglect of some children is not so surprising after all. If we don't value caring this effects both us and those around us. Human beings are relational, caring for ourselves and others is an essential part of our humanity as well as of our well-being. I don’t know if overall women have become more indifferent than men, but we should be alarmed at the increase because a society that doesn’t care ceases to be civilised. Post olympics we won’t go on feeling good if we simply remember the victories, but we will if we emulate the kind and caring volunteers. Then we can achieve an even more important result: the reversal  of indifference – and possibly prevent a few untimely deaths too.

Eighty years on and no justice for British girls subjected to FGM

As long ago as 1932, the MP Colonel Wedgwood (direct descendent of the famous potter) spoke in parliament on the “horrible practice of female circumcision” that he had seen in Kenya and questioned any acceptance of “their customs...their cruelties”. It’s a practice that involves the partial to complete removal of a girl’s external genitals which inevitably has a severely damaging impact on her physical, sexual and mental health.

Eighty years later what have we got? Two laws banning female circumcision – more commonly known as female genital mutilation (FGM) – but no prosecutions despite significant evidence that thousands of girls every year in the UK are at risk of this abusive practice.  

Newsnight have featured two excellent programmes over the past two evenings on the abhorrent practice of FGM. Last night they had a group of teenagers in the studio who boldly and rightly asked Minister Lynne Featherstone why FGM is not seen in the same light as child abuse. They were right to ask. If parents were having their daughter’s ears cut off I can’t believe the Prime Minister himself wouldn’t be denouncing it from the dispatch box and ordering a judicial enquiry.

The Newsnight programme detailed the approach in France, where apparently there have been over 100 prosecutions for FGM. There, all girls have an annual health check which includes a quick look at their genitals by a medical professional. This approach was ruled out immediately by Lynne Featherstone, but as one of the teenagers put it, all women have smear tests which are a much more invasive check, so what would be the problem with a quick visual inspection on younger girls by a nurse? More worryingly, when the discussion turned to girls being brought to England for FGM from other European countries, the Minister said that this was the first she had heard of it. Hasn’t she or her officials been reading the papers this year?

It seems quite clear to me that we need cultural change. The government need to get their act together, declare afresh that FGM is child abuse that will be prosecuted and direct some resources into investigation and prosecution. Any reports by health professionals or teachers of their concerns should be acted upon immediately. At the same time, community leaders in the UK need to establish new rites of passage for girls that don’t involve FGM but still initiate them into their culture and womanhood. These new rituals were reported on in The Lancet as long ago as 1998 and when in Kenya last month I came across several examples of faith-based rites-of-passage for girls that had replaced FGM.

The summer holidays are a prime time for FGM. Tory MP Jane Ellison initiated an excellent parliamentary debate on the subject just two weeks ago - it was a shame she wasn't on Newsnight. Girls, mostly from ethnic minorities, growing up in the UK are being betrayed if the government thinks that another discussion with officials in October is enough, which is what the Minister said she was going to do. Developing countries look to the UK and hear our talk of gender equality and intolerance of child abuse. It will remain empty rhetoric and incredibly ironic if we are left wringing our hands over this barbaric practice while they replace it with humane, gender-affirming ceremonies for girls.

Will Keith Allen's 'serious and balanced' televised drug stunt cover addiction, infection, psychosis, depression and death?

Keith Allen is a fine actor. He is also a popular celebrity well known for his drug use and flagrant contempt of the laws that ban the use of narcotics, to the extent that he is reported to have used his daughter Lily to help him sell drugs at Glastonbury.

Keith has gone on the defensive after it was revealed that he is involved in a ‘serious and balanced’ Channel 4 ‘documentary’ purporting to show reactions of participants to controlled substances, that is illegal drugs. He said on ITV1′s This Morning: “If you think that I’m glamorising the taking of drugs by spending an hour and 20 minutes for two consecutive Mondays in an MRI scanning machine then you’re insane.” He went on to describe the programme as a ‘forensic analysis’ investigating drugs.

I still stand by my original comments. This is reckless and pointless because the whole reason that we have the 1971 Misuse of Drugs Act is that we had built up a repository of evidence showing the detrimental effects of the non-medical use of various groups of drugs. We have archives of research covering both the positive medical benefits of drugs and their side effects, and the drastic results of drug misuse. This research isn’t at a standstill as we still have much to learn about modes of action and transmission, but it’s laughable to suggest that this is a serious scientific study even with Professor David Nutt of Imperial College at the helm. For starters, the exclusion criteria of a study always includes an individual’s medical history, and former use of illegal substances that have known permanent effects on the body would rule out a candidate, including Mr Allen.

It was Professor Nutt who previously suggested horse-riding is more dangerous than taking ecstasy. He may be right when it comes to the in-the-moment risk, but his analogy then crashes. Once you get off a horse the risk is over; with drugs the risks endure, and this is another reason why a programme looking at the initial reaction to drug taking is pretty pointless. The reactions from drugs can last a lifetime, vary between individuals, between the strength of drug taken (not usually known on the street) and between drugs. Whilst the initial euphoria can be impressive (and having had medical dia-morphine, more commonly known as heroin, as my pain-killer after a botched epidural I can testify to the ‘high’) will this programme be capturing the down-stream wash of physical and mental collapse?

Quite how this programme’s content contributes to the apparent discussion of a “very calm look at the question of legality and illegality of drugs” is trumped up justification. Maybe the addiction, collapsed veins, bacterial infections, abscesses, high blood pressure, muscle spasm, blurred vision, arthritis, psychosis, depression and death won’t feature as they aren’t the initial ‘reactions’ experienced?

From what we know of this programme, I can’t quite see it as anything other than a traditional Channel 4 publicity stunt. And I note that the Home Office spokesman said: 'Any unlicensed possession of Class A drugs is a criminal offence, unless this is done under authorisation from the Home Office,' without saying that this programme did have the authorisation. Hmmm.