tag:theconversation.com,2011:/global/topics/health-services-5292/articleshealth services – The Conversation2023-10-20T15:24:20Ztag:theconversation.com,2011:article/2114412023-10-20T15:24:20Z2023-10-20T15:24:20Z‘We are worn out and no one cares’: why ambulance staff in UK and Australia are ready to quit the profession<p>The COVID-19 pandemic may be over, but its scars remain for those on the frontline of the health sector – not least in the ambulance services. And our research conducted separately in the <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2023.15.8.315">UK</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/09585192.2023.2237871">Australia</a> shows things are getting worse across the globe.</p>
<p>Ambulance staff in <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2022.14.1.6">many other</a> countries, including <a href="https://www.wsws.org/en/articles/2022/12/22/ambu-d22.html">Germany</a>, <a href="https://www.connexionfrance.com/article/French-news/Health/French-emergency-services-Why-it-is-now-harder-to-reach-15-number">France</a>, <a href="http://ijomeh.eu/Predictors-of-stress-among-emergency-medical-personnel-during-the-COVID-19-pandemic,128640,0,2.html">Poland</a>, <a href="https://www.tandfonline.com/doi/full/10.1080/07853890.2022.2137735">Spain</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10093884/">USA</a>, <a href="https://www.japantimes.co.jp/news/2022/08/16/national/japan-ambulances-struggle-covid/">Japan</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824029/">Israel</a> and <a href="https://www.deccanherald.com/india/too-little-too-late-emergency-services-require-urgent-care-1216452.html">India</a>, are also facing increased pressures. This is due to more people using ambulance services, more complex patient needs, not enough staff and resources, and unmanageable workloads. All these factors have made it difficult for many ambulance services to operate.</p>
<p>We studied two services similar in size and structure: the <a href="https://ambulance.nhs.wales">Welsh Ambulance Services NHS Trust</a> in the UK, and <a href="https://www.ambulance.vic.gov.au">Ambulance Victoria</a> in Australia. We found that both services are close to a point where they may not be able to meet the needs of the people they serve. And we identified similar issues and problems in both locations which are causing many employees to consider leaving the profession.</p>
<p>We found that nearly 45% of ambulance staff in Wales and 29% in Victoria are considering quitting. And in Victoria, 16% of ambulance services staff said they were looking to leave the profession within the next year, while 23% of participants in Wales said the same.</p>
<h2>Unmanageable workloads</h2>
<p>These are highly skilled healthcare professionals who are thinking about leaving their jobs for good. The main reason staff in both services gave us is unmanageable workloads, with many echoing the sentiments of one another.</p>
<blockquote>
<p>“The workload is huge and continues to grow. I regularly work 50 plus hours per week to keep on top of everything and still struggle.” (Wales)</p>
<p>“We are consistently given demands that are impossible to achieve. We are worn out and no one cares.” (Wales)</p>
<p>“I’m falling out of love with a job that I have loved and excelled at for nearly a decade and a half. Managers are pushing [targets] and budgets and times, while on road staff are exhausted.” (Victoria)</p>
<p>“Morale is the lowest I have ever seen in the ambulance service.” (Wales)</p>
<p>“Listening to the distressing phone calls I receive from road colleagues who are struggling … There is no respite of this pressure … I am hugely concerned for my frontline colleagues’ welfare.” (Wales)</p>
</blockquote>
<p>These comments feed into the issues of staff retention in both services as demands intensify. However, there is a perceived lack of understanding and support from management and more critically, a lack of resources. The real concern lies in how this will impact the quality of care provided to patients in both places.</p>
<p>Our findings are supported by other <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/paramedics-in-pandemics-protecting-the-mental-wellness-of-those-behind-enemy-lines/C0B1C08CF27CF1AD95EAC18B43D35E21">research</a> which indicates that ambulance services staff were the most likely to <a href="https://www.bbc.co.uk/news/uk-wales-60853142">say</a> their mental health had <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2022.14.1.6">deteriorated</a> following the COVID-19 pandemic, and by default, their ability to work effectively in the longer term.</p>
<p>Our research also shows that ambulance workers in Wales and Victoria, Australia are highly engaged and passionate about their work. They identify strongly with the job that they do. But they are approaching a crisis point due to increasing workload, burnout and low morale.</p>
<figure class="align-center ">
<img alt="A yellow ambulance driving down a road." src="https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A Welsh Ambulance NHS trust ambulance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cardiff-wales-april-2021-aerial-view-1952101864">Ceri Breeze/Shutterstock</a></span>
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</figure>
<h2>Potential solutions</h2>
<p>The problems we found in our studies can be solved by ambulance management on either side of the globe. The most important thing is to provide more resources to support and retain this highly skilled workforce, which could help to reduce burnout and keep staff in this essential job.</p>
<p>Ambulance services must prioritise improving staff wellbeing, and efforts to do so should be inclusive, employee-led and proactive. Creating a stable and sustainable workforce could help in responding to changes in service and health needs. All levels of management should be given the appropriate training too. Taking these approaches could ensure that the work of ambulance services staff and other healthcare professionals is properly valued.</p>
<p>We hope that the findings from our studies will be used to create new ways to improve the workplace culture in Wales and Victoria. We also welcome other healthcare organisation using our findings to protect and support the wellbeing of their staff.</p><img src="https://counter.theconversation.com/content/211441/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research on both sides of the globe shows that unmanageable workloads is the main reason why many ambulance service staff are considering quitting the profession.Julian Hunt, Research Officer School of Health and Social Care, Swansea UniversityJohn Gammon, Deputy Head (Innovation and Engagement) of the School of Health and Social Care, Swansea UniversityPeter Holland, Professor in Human Resource Management and Employee Relations, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2077452023-09-06T15:47:37Z2023-09-06T15:47:37ZNo evidence to show whether autism health passports are effective – new review<p><a href="https://www.nhsemployers.org/publications/nhs-health-passport">Health passports</a> were developed to help patients better communicate their needs with medical staff by allowing people to record details about their disability or health condition. They are sometimes known as a communication passport, healthcare passport or a hospital passport and can be digital or on paper. </p>
<p>Autism health passports were specifically designed with the aim of achieving more equitable access to healthcare for <a href="https://www.skillsforhealth.org.uk/info-hub/learning-disability-and-autism-frameworks-2019/">autistic people</a>. But how effectively do they achieve this? </p>
<p><a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0279214">We reviewed</a> the evidence to see if they met their <a href="https://www.nice.org.uk/guidance/cg142/chapter/Recommendations">aims</a>. The literature we found tended to focus on describing the passports rather than evaluating their effectiveness.</p>
<p><a href="https://www.cdc.gov/ncbddd/autism/data.html">Around 3%</a> of the population is estimated to be autistic and autistic people experience the world differently. We have sensory, social and communication differences. We also often have co-occurring conditions such as <a href="https://www.mdpi.com/2075-4426/10/4/260">hypermobility</a>, <a href="https://www.sciencedirect.com/science/article/pii/S1525505019304949">epilepsy</a> and <a href="https://link.springer.com/article/10.1007/s11920-019-1020-5">ADHD</a>.</p>
<p><a href="https://www.legislation.gov.uk/ukpga/2010/15/contents">The Equality Act of 2010</a> states that government services – including healthcare – have a duty to provide “reasonable adjustments” for autistic people. This means organisations must make changes to how they provide their services to remove any social or environmental barriers. </p>
<p>Despite this, health services are often less accessible for autistic people. This is because such environments can include bright lights and lots of background noise which may cause physical pain and brain fog. Also, health professionals don’t always understand enough about autism to know how to communicate effectively with autistic patients.</p>
<p>This can lead to negative experiences and even <a href="http://dx.doi.org/10.1136/bmjopen-2021-056904">early death</a> for autistic people. Autistic people have reported concerns about being misunderstood or facing discrimination when they ask for medical <a href="https://doi.org/10.1177/1362361318811290">support</a>.</p>
<p>Autism health passports were introduced to overcome such challenges. For example, the “<a href="https://www.autism.org.uk/advice-and-guidance/topics/physical-health/my-health-passport">my health passport</a>” was developed in the UK <a href="https://www.nursingtimes.net/roles/learning-disability-nurses/passport-aims-to-help-autistic-patients-communicate-with-nurses-17-07-2014/">in 2014</a> by Baroness Angela Browning in collaboration with the National Autistic Society. There are other autism health passports from different organisations too.</p>
<p>Health passports have been <a href="https://www.skillsforhealth.org.uk/info-hub/learning-disability-and-autism-frameworks-2019/">endorsed</a> by the UK government, which is responsible for health in England. Using a health passport is also recommended as <a href="http://www.nice.org.uk/guidance/cg142">best practice</a> by the National Institute for Health and Care Excellence.</p>
<p>Our review identified all studies from across the globe which focused on autism health passports for people over the age of 16. We identified 13 sources in our review, of mixed quality. Four of which were not empirical and four were based in the UK.</p>
<p>We discovered that almost no information exists about whether autism health passports have achieved their aims. The studies we reviewed included information about the contents of the health passports, such as the person’s name, date of birth and communication needs. </p>
<p>But they did not say how they were supposed to be used in appointments, or include information such as who should fill out the passport, for example. What’s more, most of them did not test if the passports were effective. </p>
<p>For this reason, it is not possible to determine whether autism health passports help autistic people better access healthcare. </p>
<h2>Barriers</h2>
<p>Besides, there are already many societal, environmental and interpersonal barriers which prevent autism health passports from working effectively. </p>
<p>The general understanding of autism in society tends to be outdated, often limited to viewing it as a medical condition. Non-autistic brains are often considered as “the norm” while other types of brains can be viewed <a href="https://doi.org/10.1111/josp.12456">negatively</a> by the general population. </p>
<p>Viewing autism as a medical condition can <a href="https://doi.org/10.1177/1358229118820742">stigmatise</a> autistic people and impacts how many non-autistic people – including health professionals – engage with autistic people. </p>
<p>Many autistic people prefer the social model of disability instead. This states that society creates disability through a range of barriers that could be, but are not, removed. Autism is also an important part of some autistic people’s <a href="https://doi.org/10.1080/09687599.2021.1877117">identity</a>. </p>
<figure class="align-center ">
<img alt="An infographic displaying information about autism health passports" src="https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/539921/original/file-20230728-21-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The barriers which need to be dismantled to ensure health passports can work.</span>
<span class="attribution"><span class="source">Rebecca Ellis</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Staff who have not received autism training may be unaware of the adaptations needed to make healthcare more accessible. They may also not be aware of the co-occurring conditions that are often present alongside autism. </p>
<p>And due to staff and resource shortages, even with good knowledge of autism, health professionals may not have time to read additional materials such as an autism health passport.</p>
<h2>How to make positive changes</h2>
<p>Environmental changes are needed to provide better care for autistic people, because hospitals can be fast-paced and overwhelming places. Patients may have to move between areas of a large, often confusing, building and work with a number of different professionals, with varying levels of neurodiversity-affirming training. </p>
<p>This situation could be improved by using quiet spaces and assigning appropriately trained key workers to autistic patients. We do not think that “bolt on” tools like autism health passports are enough to create meaningful change in otherwise inaccessible health services. </p>
<p>A service redesign is necessary to meet autistic needs. Whether or not a tool such as a health passport can positively influence an autistic person’s experiences of healthcare is dependent on making wider changes to services.</p>
<p>Such initiatives should also be co-designed with autistic people to give them the greatest chance of being effective. By improving services in this way, they could meet the needs of other marginalised groups too.</p><img src="https://counter.theconversation.com/content/207745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Ellis received Health and Care Research Wales funding for their PhD. </span></em></p><p class="fine-print"><em><span>Aimee Grant receives funding from the Wellcome Trust, the Medical Research Council and the Research Wales Innovation Fund (part of HEFCW). </span></em></p>Autism health passports are a tool designed to help autistic people access healthcare more easily.Rebecca Ellis, Assistant researcher in Public Health, Swansea UniversityAimee Grant, Senior Lecturer in Public Health and Wellcome Trust Career Development Fellow, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2079082023-06-21T20:03:07Z2023-06-21T20:03:07ZIt’s 4 years since the NZ government pledged $1.9 billion for better mental health services – why are we still waiting?<figure><img src="https://images.theconversation.com/files/533081/original/file-20230621-37081-3f4pm5.jpg?ixlib=rb-1.1.0&rect=97%2C150%2C5810%2C3782&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>In 2019 the New Zealand government committed an unprecedented NZ$1.9 billion to improving <a href="https://www.beehive.govt.nz/release/taking-mental-health-seriously">mental health services</a>. This announcement brought hope to a sector that had been treated like the <a href="https://theconversation.com/mental-health-wins-record-funding-in-new-zealands-first-well-being-budget-118047">second-class citizen of the health service</a> for decades. </p>
<p>But four years later, it is clear these high hopes have not been realised. </p>
<p>It’s easy to find examples of unmet mental health needs in our communities. Fundamental gaps are evident across the sector, from <a href="https://www.nzherald.co.nz/nz/politics/youth-mental-health-wait-times-in-wellington-more-than-double/MRO66TVICJF55CXONJVIIBMNGA/">young people in crisis</a> waiting 70 days to be seen by a therapist, to <a href="https://www.nzherald.co.nz/bay-of-plenty-times/news/mental-health-tauranga-man-with-anxiety-depression-speaks-out-as-national-calls-for-mental-health-minister/643IYGXA2RDWTN2XO4BDI2MIVA/">men struggling with depression</a>, to those with more <a href="https://www.rnz.co.nz/news/national/489645/no-capacity-to-test-adults-for-adhd-a-major-issue-gps-nz-head-says">chronic conditions such as ADHD</a> struggling to receive diagnoses and care. </p>
<h2>Where did the money go?</h2>
<p>So what has happened to the billions set aside to improve mental health services? </p>
<p>Almost a quarter of the funding has gone to health improvement practitioners (HIPs) and health coaches based within general medical practices. The aim of these practitioners and coaches is to give fast and early access to people presenting to their general practitioner (GP) with <a href="https://www.procare.co.nz/news/2019/procare-welcomes-govt-2019-budget-commitment-for-mental-health-support-in-general-practice/">mental health concerns</a>. </p>
<p>Considerable investment has also gone into making mental health apps widely available to the public, a move that was at least partly <a href="https://www.beehive.govt.nz/release/apps-e-therapy-offer-practical-mental-health-support">sparked by the COVID-19 lockdowns</a>. </p>
<p>These initiatives focus mainly on providing proactive support to people with mild symptoms and/or upskilling the general population to help prevent psychological distress occurring. </p>
<h2>Robbing Peter to pay Paul</h2>
<p>This investment approach by the government has several problems, which mean the country’s collective mental health needs have not been successfully addressed. </p>
<p>Firstly, while the aims of the HIPs programme are to be lauded – it allows a quick and “warm” handover from GP to mental health clinician – it has done little to increase the pool of mental health professionals. The practitioners are drawn from the <a href="https://www.tepou.co.nz/initiatives/integrated-primary-mental-health-and-addiction/health-improvement-practitioners-in-new-zealand">existing health workforce</a>. Many nurses and psychologists have taken up practitioner roles, meaning we have robbed Peter to pay Paul as clinicians move from one area of the mental health sector to another. </p>
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Read more:
<a href="https://theconversation.com/pixels-are-not-people-mental-health-apps-are-increasingly-popular-but-human-connection-is-still-key-192247">Pixels are not people: mental health apps are increasingly popular but human connection is still key</a>
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<p>Secondly, while mental health apps often include excellent psychological tools and techniques that can enhance wellbeing, they are still largely untested, can suffer from <a href="https://www.sciencedirect.com/science/article/pii/S2214782921001330">low levels of uptake</a> and don’t always meet <a href="https://www.hpa.org.nz/sites/default/files/Digital%20Tools%20for%20Mental%20Health%20and%20Wellbeing_Report.pdf">the need for human interaction</a>. </p>
<p>Thirdly, it appears the Ministry of Health’s focus on one or two approaches to meeting our mental health demands has blinded it to other possible solutions. </p>
<p>For example, there is a <a href="https://www.ohsu.edu/sites/default/files/2019-09/An%20Observational%20Preliminary%20Study%20on%20the%20Safety%20of%20Long-Term%20Consumption%20of%20Micronutrients%20for%20the%20Treatment%20of%20Psychiatric%20Symptoms.pdf">growing body of local and international research</a> highlighting the relationship of micronutrients and what we eat to our mental health. </p>
<p>Yet this line of intervention has only recently received <a href="https://pharmac.govt.nz/assets/2022-08-combined-PTAC-meeting-record.pdf">government support</a>. Even then the investment is relatively limited.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1465385991468826627"}"></div></p>
<h2>Going global for ideas</h2>
<p>Unsurprisingly, Aotearoa New Zealand is not the only country to be grappling with high demand for mental health services. We can learn from what other countries are doing in response to gaps in their services.</p>
<p>The United Kingdom, for example, has attempted to address its own mental health services shortfall with a programme called <a href="https://www.healthcareers.nhs.uk/explore-roles/psychological-therapies/roles/high-intensity-therapist">Increasing Access to Psychological Therapies (IAPT)</a>. This is a limited talking therapies programme that is commonly offered to people struggling with anxiety and depression. </p>
<p>Since its launch in 2008, 10,500 additional psychological therapists and practitioners have been trained to work with IAPT referrals. According to recent <a href="https://www.england.nhs.uk/mental-health/adults/nhs-talking-therapies/service-standards/#:%7E:text=Waiting%20times%3A%2075%25%20of%20people,within%2018%20weeks%20of%20referral.">National Health Service data</a>, 75% of people referred to IAPT services start treatment within six weeks of referral, and 95% start treatment within 18 weeks.</p>
<p>As with any programme developed overseas its applicability in New Zealand would need to be tried and tested but, on its face, IAPT offers some potential solutions. Yet there has been little to no interest in this approach from the current government. </p>
<h2>Real action is long overdue</h2>
<p>The government’s singular focus on one or two new mental health initiatives has been at the expense of training programmes. In 2021, the then health minister, Andrew Little, claimed New Zealand did not need an <a href="http://www.beehive.govt.nz/sites/default/files/2021-09/All%20of%20Government%20Press%20Conference%2024%20September%202021.pdf">“army” of psychologists</a> but given we are at least <a href="https://www.renews.co.nz/new-zealand-needs-1000-more-psychologists-and-its-hurting-people/">1,000 psychologists short</a> a battalion would be welcome. </p>
<p>If even a quarter of the funding that has been funnelled to new initiatives had been invested in 2019 in existing psychology training programmes, we could have doubled the numbers of psychologists graduating into the health workforce. </p>
<p>To give the government its due, there has been some <a href="https://www.beehive.govt.nz/release/govt%E2%80%99s-mental-health-roll-out-gains-momentum-%E2%80%93-more-funds-and-internships-clinical">recent investment in clinical psychology training</a> but it feels like an afterthought. It is also still very small compared to investment in other areas. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/road-to-nowhere-new-zealanders-struggle-to-get-the-help-they-need-2-years-on-from-a-funding-boost-for-mental-health-services-158868">Road to nowhere: New Zealanders struggle to get the help they need, 2 years on from a funding boost for mental health services</a>
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<p>The four years that have passed since the government’s bold commitment to addressing our mental health crisis has included several large bumps in the road that would have disrupted even the best-laid plans. Our leaders have had to deal with a physical health pandemic and a restructure of the entire health system. The former was out of anyone’s control, the latter very much of the government’s own making. </p>
<p>Nonetheless, looking at our mental health system in 2023 it feels like very little progress has been made. A blinkered approach to how to spend the $1.9 billion of our health dollars has stymied any good intentions that were behind the original plan.</p><img src="https://counter.theconversation.com/content/207908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dougal Sutherland is an Adjunct Teaching Fellow at Te Herenga Waka and also works for Umbrella Wellbeing. </span></em></p>A focus on the lower end of mental health issues has meant those in crisis are still not getting the level of support they need.Dougal Sutherland, Clinical Psychologist, Te Herenga Waka — Victoria University of WellingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1481832020-10-19T04:08:13Z2020-10-19T04:08:13ZAs holidaymakers arrive, what does COVID-19 mean for rural health services?<p>At the start of the pandemic, health services in regional cities and small towns braced for a tsunami of cases. Many worried the patient transport system between hospitals would fail, and each hospital would be left to fend for itself. Small hospitals planned makeshift intensive care departments with improvised long-term ventilators. And health-care teams drilled themselves in how they would manage a COVID-positive patient who was deteriorating.</p>
<p>Fortunately, in Australia, these dire predictions were wrong (at least for now). But they could have been right. Rural areas are not immune to COVID-19. In the United States, the current <a href="https://dailyyonder.com/rural-infection-rate-surpasses-metro-americas-all-time-high/2020/10/15/">rural infection rate</a> is higher than has ever been recorded in metropolitan areas. A <a href="https://www.theguardian.com/world/2020/apr/08/rural-hospital-coronavirus-covid-19-louisiana-new-orleans">Louisiana hospital</a> described exactly the makeshift intensive care scenario we feared in Australia. Rural patients are more vulnerable too, as the community is older with more chronic health problems.</p>
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Read more:
<a href="https://theconversation.com/rural-america-is-more-vulnerable-to-covid-19-than-cities-are-and-its-starting-to-show-140532">Rural America is more vulnerable to COVID-19 than cities are, and it's starting to show</a>
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<p>In rural Australia, dealing with the pandemic has been more like whack-a-mole than an overwhelming wave. Outbreaks occurred around meatworks, local hospitals, and super-spreaders travelling from hotspots.</p>
<p>So, what have we learned so far about the impact of COVID-19 on rural health, and how can we maintain effective rural health care as tourism ramps up?</p>
<h2>We must work together</h2>
<p>A pandemic lays bare pre-existing structural problems. It exposes the lack of formal channels for rural clinicians to communicate across disciplines and across regions. It reveals the barriers between clinicians in the hospitals and bureaucrats in regional and city offices.</p>
<p>But it also provides an opportunity to connect these groups. During the pandemic, health services across different regions and states shared <a href="https://acem.org.au/getmedia/3ecc6790-6751-478a-9114-080040282476/Rural-Emergency-Toolkit-v1-0">local solutions</a>. Public health, hospital, community care and inter-hospital services created joint protocols. New communication channels must be maintained and ready for activation if cases increase. </p>
<p>Local knowledge remains important. Embedding local health workers in contact-tracing teams is a strength of <a href="https://theconversation.com/where-did-victoria-go-so-wrong-with-contact-tracing-and-have-they-fixed-it-147993">NSW’s pandemic defences</a>.</p>
<p>As the Victorian town of Shepparton discovered last week, local outbreaks cause an immediate and massive demand for <a href="https://www.theage.com.au/national/victoria/shepparton-goes-quiet-as-community-sweats-on-test-results-20201015-p565io.html">testing</a>. Using local media to keep rural communities up to date enhances the remarkable support already shown for quarantine measures.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1317265509222473728"}"></div></p>
<p>Teleconferencing between clinicians has expanded, as it has between clinicians and patients. It is best and most geographically equitable when it adds to face-to-face local care.</p>
<p>But it may also detract from enabling the best care when it <a href="https://www.smh.com.au/national/we-couldn-t-believe-it-woman-bleeds-to-death-in-nsw-hospital-with-no-doctors-on-site-20201011-p563z1.html">replaces</a> clinicians on the ground. One possible example is that of a woman who died in the emergency department of a regional NSW hospital in September. No doctors were present in person, having been replaced by telehealth treatment outside business hours.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/where-did-victoria-go-so-wrong-with-contact-tracing-and-have-they-fixed-it-147993">Where did Victoria go so wrong with contact tracing and have they fixed it?</a>
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<h2>Self-reliance and silent hypoxia are a bad combination</h2>
<p>Identifying patients before they become critically ill is crucial to rural acute care. This is true for COVID-19. The disease has a reasonably <a href="https://www.nejm.org/doi/full/10.1056/NEJMcp2009575?query=featured_coronavirus">predictable path</a> of early fever, improvement, and then a sometimes <a href="https://theconversation.com/tested-positive-for-covid-19-heres-what-happens-next-and-why-day-5-is-crucial-143687">rapid deterioration in the second week</a>. For all but large regional centres, this means COVID-19 is managed in the community. Deteriorating patients need to be transferred early.</p>
<p>Unfortunately, COVID-19 has a horrible trick. It can cause extremely low levels of blood oxygen without a patient feeling unwell or breathless, or realising their oxygen levels are critically low. This is called <a href="https://www.health.com/condition/infectious-diseases/coronavirus/silent-hypoxia">silent hypoxia</a>.</p>
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<img alt="A person with a pulse oximeter on their finger, measuring their blood oxygen levels" src="https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364142/original/file-20201019-13-sq3yn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Many rural health services have used remote oxygen monitoring tools so clinicians can check in on patients recovering at home.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>It’s a problem everywhere, but it may be <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2023540">worse in rural areas</a>. Patients often visit regional hospitals at a later stage of their illness due to self-reliance, distance to care, and a poorer understanding of the health system. By the time a rural COVID-19 patient thinks they are unwell enough to attend, they may already be close to dying.</p>
<p>Rural health services have had to adopt policies of regular local and remote checking-in for COVID-19 patients, especially in the second week. Telephone and internet connections are not always enough, so many hospitals have bought oxygen-monitoring tools for patients to use at home.</p>
<h2>Maintaining normal services is difficult</h2>
<p>COVID-19 need only infect a few staff at regional hospitals to make service delivery impossible. In <a href="https://www.abc.net.au/news/2020-07-12/what-can-victoria-learn-tasmania-coronavirus-covid19-response/12445736">northwest Tasmania</a>, Australian Defence Force members had to replace infected and quarantining staff in mid-April.</p>
<p>Even without an outbreak, COVID makes it difficult to maintain normal operations. Health services relying on fly-in fly-out staff have struggled when staff can no longer travel freely across quarantine lines from the city or across state borders. Exemptions were given but the approval process was slow and many staff still had to do periods of self-quarantine, meaning many staff found it too difficult. Mechanisms to replace or increase staff may still be needed for regions with outbreaks.</p>
<p>Although rural hospitals have been spared the overwhelming numbers of COVID-19 seen in Melbourne hospitals, the extra precautions required to manage patients who could potentially have COVID-19 are draining. Maintaining services reliant on supplies at the end of the supply and logistics chain is slower and challenging. Like metropolitan staff, rural staff are feeling <a href="https://www.nswrdn.com.au/site/index.cfm?module=news&pagemode=indiv&page_id=1072042&pageReload=yes">fatigued</a> and requiring extra mental health support.</p>
<p>This is a problem as people move to rural areas for holidays and business. Even in normal years, health services in coastal and other tourist towns are busiest when the population swells in summer. With bookings of holiday accommodation <a href="https://www.abc.net.au/news/2020-09-27/nsw-covid-restrictions-see-sydney-travellers-head-regional-coast/12701876">booming</a> in many areas, rural health services may be facing their busiest and most tiring part of the pandemic. If holidaymakers feel leaving the city means leaving behind the risk of infection and the need to socially distance, the results in some rural towns may be catastrophic.</p><img src="https://counter.theconversation.com/content/148183/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Baker receives funding from Alcoa of Australia. </span></em></p><p class="fine-print"><em><span>Cameron Knott is affiliated with Australia New Zealand Intensive Care Society and is Deputy Chair of the Victorian Regional Committee of the College of Intensive Care Medicine (Australia and New Zealand).</span></em></p>Rural patients’ self-reliance means they often wait until it’s too late to visit hospital, while the closing of state borders has restricted the movement of some fly-in fly-out health workers.Timothy Baker, Associate Professor and Director, Centre for Rural Emergency Medicine, Deakin UniversityCameron Knott, Honorary Clinical Lecturer, Department of Critical Care & Rural Clinical School, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1457772020-09-30T15:06:00Z2020-09-30T15:06:00ZInsights into how the US abortion gag rule affects health services in Kenya<figure><img src="https://images.theconversation.com/files/356925/original/file-20200908-18-1ezluo5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">US President Donald Trump speaks at the 47th March For Life rally on the National Mall, January 24, 2019 in Washington, DC.</span> </figcaption></figure><p>The Mexico City Policy – often referred to as the “Global Gag Rule” – is a US government policy <a href="https://trumpglobalgagrule.pai.org/understanding-the-policy/">that requires</a> non-governmental organisations (NGOs) that are not based in the US and that receive US global health assistance to certify that they will not provide, refer for, counsel on, or advocate for abortion as a method of family planning. The rule <a href="https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">also applies</a> to any non-US funding that the organisation may receive. </p>
<p>The policy was rescinded by President Obama in 2009 but then <a href="https://www.whitehouse.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/">reinstated and expanded</a> by President Trump in 2017. While prior iterations applied only to family planning assistance (US$575 million in 2016), <a href="https://pai.org/newsletters/stroke-pen-trumps-global-gag-rule-dramatically-expands-harmful-health-impacts/">Trump’s new version</a> extends the restrictions to nearly all US global health assistance – an estimated US$9.5 billion – which includes funding for HIV/AIDS, malaria, and maternal and child health. For example, it now <a href="https://gh.bmj.com/content/4/5/e001786">means that</a> an organisation that provides HIV care and treatment with US funding may not also provide safe abortion.</p>
<p>The global gag rule includes exceptions for cases of rape, incest, and to save the life of the woman; however, these are rarely applied in practice. </p>
<p>For over 50 years US Global Health Assistance <a href="https://www.usaid.gov/global-health">has provided</a> support to developing countries around three strategic priorities: to prevent child and maternal deaths, control the HIV/AIDS epidemic, and combat infectious diseases. </p>
<p>Kenya relies heavily on foreign aid to finance its sexual and reproductive health services. The vast majority of this aid (<a href="https://stats.oecd.org/">95% in 2018</a>) comes from the US government. There are also <a href="https://www.gao.gov/assets/710/705388.pdf">approximately</a> 71 active US global health awards to various NGOs that were subject to this rule.</p>
<p>The African Population and Health Research Center, in partnership with the Global Health Justice and Governance Program of Columbia University, carried <a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412">out a study</a> to establish how Trump’s expanded rule affected sexual and reproductive health services including family planning, safe abortion, and post-abortion care in Kenya. </p>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/26410397.2020.1794412">We found</a> that in the first 18 months, the expanded rule’s effects transcended the limitation of abortion care. It affected funding and disrupted collaboration and health promotion activities. It also strengthened opposition to sexual and reproductive health and rights.</p>
<p>These losses weaken NGO support to the Kenyan health system and, we believe, will likely have a substantial impact on clients seeking sexual and reproductive health services.</p>
<p>Our findings call for harm mitigation interventions by advocates, donors and policymakers in Kenya and the United States. </p>
<h2>Implications</h2>
<p>We drew our data from in-depth interviews conducted in September 2018 and March 2019 with representatives of 18 local and international NGOs. These implemented sexual and reproductive health, HIV or other health services. We also interviewed 37 health workers whose facilities received support from an NGO for their services, meaning they could be affected by the policy via these NGOs.</p>
<p>We found that the policy had far-reaching implications. </p>
<p>NGOs were forced to choose between providing safe legal abortion services and accepting US global health funding. NGOs that turned down US funding had to then find replacement funding from other sources. This led to health facilities being closed, frequent contraceptive stockouts, staff layoffs and salary cuts. It also led to the curtailment of community-based activities, such as community health volunteers referring women for services. </p>
<p>In addition, NGOs that provided comprehensive integrated sexual and reproductive health services – such as HIV, child health and maternal health – reported closure of some components of their service delivery when they were forced to choose between US funding and funding for these other services. This meant that women encountered more difficulties obtaining these services.</p>
<h2>Ambiguous</h2>
<p>We also found that the Global Gag Rule is ambiguous (and confusing) (we believe purposefully so), leaving ample room for over-interpretation. This led to organisations reducing or ending services not restricted by the rule, such as post-abortion care, out of fear of violating the policy. </p>
<p>The policy also emboldened opponents of sexual and reproductive health and rights and safe abortion. This stifled the efforts of those advocating for safe and quality care. It also compounded existing legal, policy and cultural barriers in the delivery of these services.</p>
<h2>Partnership disruption</h2>
<p>The Global Gag Rule created divisions between NGOs that chose to comply with the policy and those that declined to do so. This led to the disruption of existing coalitions and partnerships. In addition, some compliant NGOs no longer referred clients for permitted services to non-compliant NGOs.</p>
<p>As one interviewee from a non-US NGO said:</p>
<blockquote>
<p>It’s impossible to partner with a US-funded organisation…We are working in silos…we cannot work in the same space. Even in terms of being invited in meetings, you would feel like you are being stigmatised, in fact not invited in those places, yeah, because you do not believe in the Global Gag Rule, and you are pro-choice.</p>
</blockquote>
<p>What does this mean for Kenya?</p>
<p>The US <a href="https://stats.oecd.org/">provides</a> 55% of Kenya’s development aid for health and 95% of sexual and reproductive health aid. </p>
<p>In light of evidence of the effects of this policy, the US government should reconsider how it affects people living in different contexts. And the Kenyan government must figure out how to lessen the impact of the global gag rule on its health system.</p>
<p>It is critical for the Kenyan government to look to its own policies and increase budgetary allocation for sexual and reproductive health services so that they cushion the impact of the global gag rule.</p>
<p>In addition, policymakers in the US should work to permanently repeal the policy in light of ample evidence demonstrating its adverse impact.</p><img src="https://counter.theconversation.com/content/145777/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Global Gag Rule transcends abortion and exacerbates weaknesses and vulnerabilities of the Kenyan health system.Boniface Ushie, Research Scientist, African Population and Health Research CenterSara E Casey, Assistant Professor, Heilbrunn Department of Population and Family Health, Columbia UniversityTerry McGovern, Chair, Heilbrunn Department of Population and Family Health, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1262722019-11-07T04:20:46Z2019-11-07T04:20:46ZQueensland Health’s history of software mishaps is proof of how hard e-health can be<figure><img src="https://images.theconversation.com/files/300581/original/file-20191107-12495-9a0n6z.jpg?ixlib=rb-1.1.0&rect=0%2C35%2C3994%2C2628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Queensland Health's current electronic medical records system is what you could call a "monolithic" system, meaning it's an all-in-one system designed by one company. Such systems may not be the best option for the health sector's future. </span> <span class="attribution"><span class="source">SHUTTERSTOCK</span></span></figcaption></figure><p>A directive ordering Queensland Health staff to avoid upgrades to the state’s hospital electronic medical record system during parliamentary sitting weeks <a href="https://www.brisbanetimes.com.au/national/queensland/leaked-queensland-health-email-reveals-order-to-halt-it-upgrades-during-parliament-20191031-p5367x.html">was recently reversed</a>. After the email containing the directive was leaked, the state’s health minister Steven Miles revoked the directive. He said the timing of upgrades should be based on “what’s best for clinical care”.</p>
<p>Queensland’s integrated electronic medical record system (ieMR) is designed to provide information about patients in the state’s health system. The ieMR was built by Cerner, a global provider of electronic medical record software. Like any IT project of this scale, it’s extensively customised for Queensland Health and individual hospitals.</p>
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<img alt="" src="https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300577/original/file-20191107-12506-1cdsory.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The directive to avoid the ieMR upgrades was overturned after an email to Queensland Health staff was leaked to the media.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
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<p>The directive to refrain from ieMR upgrades during sitting weeks seems to be connected to 38 system outages earlier this year. Most of these happened following upgrades performed by Cerner. On at least one occasion, upgrades didn’t go smoothly, and led to system outages that required clinicians to <a href="https://www.brisbanetimes.com.au/national/queensland/more-trouble-for-queensland-hospital-software-after-statewide-issues-20190911-p52q46.html">revert to paper-based methods</a>. </p>
<p>The rollout of the <a href="https://www.health.qld.gov.au/clinical-practice/innovation/digital-health-initiatives/queensland/integrated-electronic-medical-record-iemr">ieMR system</a> to new hospitals, which began back in 2011, was put on hold earlier this year. </p>
<h2>Monolithic systems may not be the future</h2>
<p>A major difficulty with “monolithic” (that is, all-in-one systems developed by a single company) e-health systems is that a single design team is attempting to solve an incredibly broad set of complex problems. </p>
<p>Health systems involve interactions between dozens of different types of highly trained professionals. Building software to effectively support just one speciality to do its job efficiently is enormously challenging. Developers of unified electronic medical record systems must build systems that support dozens of them. As a result, it’s unlikely that such systems provide the best possible solutions for any particular speciality.</p>
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Read more:
<a href="https://theconversation.com/everything-you-need-to-know-about-australias-e-health-records-5516">Everything you need to know about Australia's e-health records</a>
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<p>Because of this, research and development in e-health systems is moving away from monolithic, one-size-fits-all systems. Companies are instead working on allowing smaller, more specialised health IT systems to work together using <a href="https://en.wikipedia.org/wiki/Fast_Healthcare_Interoperability_Resources">parallel systems designed to work in concert</a>. </p>
<p>In theory, this means clinicians and departments will be able to use the best software for their particular requirements, while each system can communicate with the others in a common language.</p>
<p>Of course, it won’t be quite that simple in practice. But Queensland Health’s current adoption of massive centralised systems imposed from the top down is extremely hard to get right.</p>
<h2>A history of e-health system problems</h2>
<p>The ieMR project isn’t the first time Queensland Health has had difficulties with a health-related IT system. An attempt to replace the payroll system, prompted in the late 2000s, was disastrous. </p>
<p>The <a href="http://www.healthpayrollinquiry.qld.gov.au/">Commission of Inquiry report</a> into the payroll system is such a compelling description of an IT project failure that I use it to show my undergraduate students an example of what not to do. </p>
<p>The report describes a litany of problems including conflicted advisers, unrealistic timetables, woefully insufficient attention to software requirements, inadequate testing and, to top it all off, a lack of any contingency plan in case the system wasn’t ready in time. This led to the deployment of a system with known critical flaws. </p>
<p>The results were predictably catastrophic, costing the state hundreds of millions of dollars.</p>
<p>It’s important to point out, however, that the ieMR is a completely separate system. Nonetheless, a consultant’s report in 2014 <a href="https://www.brisbanetimes.com.au/national/queensland/no-lessons-learned-from-payroll-disaster-queensland-health-was-warned-20190129-p50u8l.html">reportedly said</a> “no lessons have been learned” from the earlier payroll system disaster.</p>
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Read more:
<a href="https://theconversation.com/app-technology-can-fix-the-e-health-system-if-done-right-49891">App technology can fix the e-health system if done right</a>
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<p>While later efforts attempted to fix issues identified at that time, decisions made previously - especially major architectural decisions such as the choice of a particular off-the-shelf software system - cannot easily be undone.</p>
<h2>The problems are varied</h2>
<p>Difficulty managing service upgrades is <a href="https://www.brisbanetimes.com.au/topic/e-health-queensland-1mlk">one of many challenges</a> the ieMR project has faced. Other issues identified include:</p>
<ul>
<li>extensive delays in the rollout across hospitals</li>
<li>cost increases and an inability to accurately <a href="https://www.brisbanetimes.com.au/national/queensland/queenslanders-health-at-risk-from-electronic-medical-record-software-clinicians-say-20190129-p50u8i.html">predict deployment costs</a></li>
<li>concerns that software settings may have <a href="https://www.brisbanetimes.com.au/national/queensland/baby-born-with-brain-damage-after-fragmented-care-at-queensland-hospital-20190301-p5119a.html">compromised the flow of information</a> between clinicians treating a pregnant woman with serious health problems.</li>
<li>other patient safety concerns, including <a href="https://www.brisbanetimes.com.au/national/queensland/alerts-warn-of-patient-risk-software-glitches-in-electronic-medical-record-20190315-p514nl.html">corrupted medication records</a>. While no specific health events were reported as a result of this, incorrect medication poses an obvious safety concern.</li>
</ul>
<h2>Other states have struggled, too</h2>
<p>While the concept of electronic medical records is attractive to clinicians and administrators alike, Queensland Health is not the only health operator to have struck trouble with electronic medical records projects. </p>
<p>Emergency departments in New South Wales hospitals implemented a new electronic medical records system (also supplied by Cerner) in 2009 as part of a planned statewide rollout. The system was <a href="https://www.itnews.com.au/news/nsw-health-to-act-on-firstnet-issues-265617">unpopular with clinicians</a>, and one peer-reviewed academic study indicated it was <a href="https://www.mja.com.au/journal/2013/198/4/effect-electronic-medical-record-information-system-emergency-department">associated with longer emergency department wait times</a>.</p>
<p>Since the commencement of the ieMR project in 2011, <a href="https://www.abc.net.au/news/2018-12-04/digital-hospitals-blow-out-auditor-general-scathing-report/10581322">hundreds of millions of dollars</a> have been invested. Sunk costs of this kind, and institutions that tend to follow the status quo, often discourage critical analysis and the exploration of alternative paths. </p>
<p>As the decision has been made to pause the rollout, now seems like an opportune time to properly consider whether current e-health system architecture is the best option for the future. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/electronic-health-records-review-set-to-ignore-consumer-interests-20563">Electronic health records review set to ignore consumer interests</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/126272/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Merkel is a member of the Australian Greens.</span></em></p>Past upgrades to the state’s medical record system have cost tremendous amounts of money, and on at least one occasion, forced clinicians to revert to paper-based methods.Robert Merkel, Lecturer in Software Engineering, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1112772019-02-19T14:39:42Z2019-02-19T14:39:42ZMalawi’s health system puts women first. This isn’t always a good thing<figure><img src="https://images.theconversation.com/files/258785/original/file-20190213-181623-1u2a41t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women in Malawi visit clinics many more times in their lives than men.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Policymakers, donors and international agencies have, for decades, <a href="https://www.who.int/pmnch/activities/advocacy/globalstrategy/2016_2030/en/">emphasised</a> the need to prioritise women’s health services – for their own health as well as their children’s. </p>
<p>While there is an increasing awareness of – and concern about – the fact that men’s health has been <a href="https://theconversation.com/search/result?sg=3b0e2c0c-7528-4631-b6b4-d4d06a9673cd&sp=1&sr=7&url=%2Fdying-from-a-treatable-disease-hiv-and-the-men-we-neglect-55176">neglected</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782744/">global money</a>, international and national priorities continue to focus on the health of women and children.</p>
<p>And it’s working. In Malawi, where we (a group of public health and sociology researchers) work, waiting rooms are filled with young women, mothers and children seeking routine health services such as family planning, prenatal care and immunisations. Women are deeply engaged in the health system. As a result, clinics have a distinctly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4454403/">feminine flavour</a>, often characterised by groups of women and their children receiving health education and singing songs about reproductive health or immunisation strategies.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dying-from-a-treatable-disease-hiv-and-the-men-we-neglect-55176">Dying from a treatable disease: HIV and the men we neglect</a>
</strong>
</em>
</p>
<hr>
<p>We <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0209586">recently</a> completed a study on health service recommendations for young adults (aged between 18 and 35) in Malawi. We wanted to establish what these recommendations mean – in terms of commitment – for women’s time versus men’s time. What we found provides a unique perspective on the complex realities of health services, and the potential unintended consequences of focusing routine health care almost exclusively on women. These consequences may actually detract from gender equality for women, as well as from men’s health.</p>
<h2>What we found</h2>
<p>Malawi’s health service <a href="http://www.health.gov.mw/index.php/policies-strategies">guidelines</a> recommend that young women receive multiple health services: 10 times a year when they are pregnant, up to 17 times a year if they have a young child, and between four and 12 times a year for family planning. These figures only refer to routine health services, and exclude many illnesses such as malaria or respiratory infections which are common in the country and require additional visits.</p>
<p>These routine health services add up during a woman’s reproductive years. In countries with high fertility – women in Malawi have an average of <a href="https://dhsprogram.com/publications/publication-fr319-dhs-final-reports.cfm">4.4</a> children – women spend much of their young adult lives pregnant or with young children. As a result, they are constantly using health services.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=690&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=690&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=690&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=867&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=867&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258787/original/file-20190213-181627-hw7wm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=867&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Men seem out of place in this clinic in Lilongwe, Malawi.</span>
<span class="attribution"><span class="source">Kathryn Dovel</span></span>
</figcaption>
</figure>
<p>In distinct contrast, men are almost absent from national guidelines. The only preventative recommendations for men of reproductive age are circumcision (a one-time event) and an annual HIV test. </p>
<p>The gendered differences in health service guidelines for routine care mean that women are expected to attend between 176 and 433 health services over their reproductive lifespan (from the age of 15 to 44), compared to only 30 services for men.</p>
<p>Accessing health services in Malawi is a time-consuming endeavour. People travel long distances to clinics and endure long waiting times. This is exacerbated when services are not integrated, meaning that each health service often requires a separate visit to a facility, on separate days.</p>
<p>The time spent seeking health services comes at the expense of other potential activities. </p>
<p>We found that women in Malawi living with HIV would need the equivalent of one working day each month to meet routine health service guidelines. This is more than the average US worker receives annually in <a href="https://www.bls.gov/opub/ted/2016/mobile/number-of-paid-sick-leave-days-in-2015-varies-by-length-of-service-and-establishment-size.htm">paid sick leave</a>. It constitutes significant time that is lost to women’s employment, school and leisure. Additionally, we found that women spent six times as long seeking health services as men did. This increased time burden could deepen existing gender inequalities and limit women’s success outside the home.</p>
<p>But this disparity cuts both ways. </p>
<p>By excluding men from routine health services, the health system perpetuates the “tough man” mentality and reinforces notions that men should wait until they get ill before seeking care. Men’s poor use of health services has major implications for their health and – ultima
tely – their lives. Men have a <a href="https://vizhub.healthdata.org/gbd-compare/">greater burden</a> of nearly all major diseases in Malawi.</p>
<h2>Way forward</h2>
<p>More needs to be done to improve health services in Malawi. Many goals such as equality, empowerment, and health are deeply connected and require a more holistic approach so that a focus on one does not impede the others.</p>
<p>Health service guidelines must be revised to reduce the time burden on women, and to include a focus on men’s health. Existing proposals to integrate and offer outreach of routine services for women need to be implemented. At the same time, strategies to engage men must be taken up urgently. These include the provision of broader male-friendly health services that are available after hours, quick, private, and outside female-focused settings. </p>
<p>For these changes to be successful, donors and international agencies must address their blindness towards <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-3156.2011.02767.x">men’s health</a> and the time burden placed on women.</p><img src="https://counter.theconversation.com/content/111277/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn Dovel receives funding from the National Institute of Mental Health and the U.S. Agency for International Development (USAID). The content does not necessarily represent the official views of funders. </span></em></p><p class="fine-print"><em><span>Dr Morna Cornell receives funding from the National Institute Of Allergy And Infectious Diseases of the National Institutes of Health and a grant awarded jointly by the US National Institute of Mental Health & the South African Medical Research Council.
The content of this paper is solely the responsibility of the author and does not necessarily represent the official views of the US National Institutes of Health or the South African Medical Research Council.
</span></em></p><p class="fine-print"><em><span>Sara Yeatman receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The content does not necessarily represent the official view of the funder.</span></em></p><p class="fine-print"><em><span>Stephanie Chamberlin receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The content does not necessarily represent the official view of the funder.</span></em></p>Female-centred health services are good, but they may detract from gender equality and men’s health.Kathryn Dovel, Assistant Professor, University of California, Los AngelesDr Morna Cornell, Senior Researcher, University of Cape TownSara Yeatman, Associate Professor in the Department of Health and Behavioral Sciences, University of Colorado DenverStephanie Chamberlin, PhD student in Health and Behavioral Sciences,, University of Colorado DenverLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1017682018-12-10T16:33:19Z2018-12-10T16:33:19ZIslamophobia and media stigma is having real effects on Muslim mothers in maternity services<figure><img src="https://images.theconversation.com/files/248687/original/file-20181204-126662-flk0fp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4256%2C2828&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many Muslim women say prejudice stops them from talking about their religion with healthcare staff.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Negative portrayals of Islam and Muslims <a href="https://www.pressgazette.co.uk/dossier-of-20-inaccurate-uk-news-stories-about-muslims-revealed-with-warning-coverage-fuels-the-far-right/">are everywhere</a>. You don’t have to look far to find <a href="https://www.huffingtonpost.co.uk/entry/darren-osborne-islamophobia-in-uk-media_us_594982bee4b00cdb99cb01b9">stigmatising, offensive and biased news reports</a> – all of which significantly <a href="https://theconversation.com/eight-ways-that-islamophobia-operates-in-everyday-life-64444">impact how Muslims generally see the world</a> they live in. </p>
<p>These experiences <a href="https://theconversation.com/university-can-feel-like-a-hostile-place-to-muslim-students-74385">influence Muslim people’s day-to-day lives</a> – and can play a role in how Muslim people conduct themselves on a daily basis. In my <a href="http://researchonline.ljmu.ac.uk/7412/7/2017ShaimaHassanPhD.pdf">PhD study</a>, I looked at the experiences of Muslim women engaging with UK maternity services. What I found was that Muslim women lacked confidence in discussing their concerns. Most specifically health concerns related to religious practices, such as fasting or wanting to see a female doctor.</p>
<p>The ladies I spoke to felt reluctant to ask healthcare professionals questions related to their religious needs. As one participant explained:</p>
<blockquote>
<p>I could not say I am fasting which sounds extreme. Honestly, people just hear the word fasting and they think that you are so extreme.</p>
</blockquote>
<p>The anticipation of healthcare professionals not having a positive opinion of them being Muslim women in general and of their religion as a whole was strongly felt among most Muslim women in the study. </p>
<p>This anticipation was not specifically an outcome of a negative encounter during their care, but was associated with the women’s concerns of Western media portrayal of Islam and Western attitudes towards Muslims in general.</p>
<h2>Stigmatisation</h2>
<p><a href="https://www.tandfonline.com/doi/abs/10.1080/1369183X.2014.1002200">Research has shown</a> how the representation of Muslims in Western media became significantly more negative following the events of 9/11. Over this period the British press has often used a <a href="https://eclass.upatras.gr/modules/document/file.php/PDE1357/Media%20%26%20Islamophobia.pdf">negative tone in presenting British Muslims</a>, which makes them seen as an “alien other” within British society. This negative tone has only become worse with the dramatically increased coverage of radical groups such as Daesh. </p>
<p>Often the media makes distinctions between the actions of radical Muslims and the beliefs and actions of “mainstream” or “moderate” Muslims. Making it sound like there are “good” and “bad” Muslims. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/248702/original/file-20181204-34131-13qdunk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many of the Muslim women spoke of wanting to hide aspects of their religion.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Muslim women, in particular, are often portrayed as <a href="https://www.researchgate.net/publication/261708841_Discourse_Analysis_and_Media_Attitudes_The_Representation_of_Islam_in_the_British_Press_1998-2009">victims and oppressed</a>. There is often a greater focus on their outer appearances. This is especially true for Muslim women who wear the face veil (burqa, also known as a niqab), which has long been portrayed as a symbol of oppression. The burqa has become a hot topic of debate in politics, arts and literature, <a href="https://www.ksk.edu.ee/wp-content/uploads/2012/12/KVUOA_Toimetised_14_8_eero_janson.pdf">even though it is estimated</a> that 90% of Muslim women in the world do not wear the Burqa – even in most Muslim countries.</p>
<p>Debates and policy in Europe about banning or <a href="https://www.ksk.edu.ee/wp-content/uploads/2012/12/KVUOA_Toimetised_14_8_eero_janson.pdf">regulating wearing the veil</a> contribute to the assumptions that if Muslim women wearing Islamic garments had a choice, they would not wear headscarves, burqa or any such clothing. Because of this rhetoric, it is often believed that Muslim women are oppressed and need to be saved. </p>
<h2>‘Oppressed, young and married’</h2>
<p>It is because of <a href="https://www.tandfonline.com/doi/abs/10.1080/00313220903109326">such assumptions</a>, that the Muslim women in the study, believe healthcare professionals would also have similar beliefs – as one of the participants in the study explained: </p>
<blockquote>
<p>They think that we are oppressed, young and married, and all these things they have about us that is negative.</p>
</blockquote>
<p>For Muslim women this was not the image they want be identified with. They spoke of wanting to negate such representation created by Western media – but by doing so, feared they would be judged and misunderstood. </p>
<p>Most of the women in our study felt that they had to explain themselves every time their religion was mentioned. So rather than just asking for what they need, they felt the need to explain why they want to be seen to by a female healthcare professional or why they would like their curtains to be closed in the ward or why they cannot have medication that doesn’t meet their dietary requirements.</p>
<h2>Avoiding the issue</h2>
<p>Some white British women who became Muslim even felt the need to explain that being Muslim was their choice – mainly to ensure healthcare professionals didn’t make the assumption they had been forced into religion. </p>
<p>As for others, they felt that doctors and nurses wouldn’t understand or acknowledge their religious needs. So they would avoid discussing them freely – even though they wanted a doctor’s or midwife’s opinion on certain religious practices during pregnancy. One of the ladies we spoke to explained how she felt the need to hide why she needed to change her appointment: </p>
<blockquote>
<p>I phoned up to change my appointment so it could be before the start of Ramadan. When I was asked the reason for me changing the appointment, I could not say that ‘I will be fasting for Ramadan’ so I just said that I will be travelling out of the country. </p>
<p>I think people do not understand actually how important our religion is to us … I feel we are forced to hide certain things to make it easier for people not to think our religion is demanding. </p>
</blockquote>
<p>What all this shows is that there is a real risk of depriving Muslim women access to the care they need. Muslim women need to feel safe to express their needs in health environments. And this means healthcare professionals need to be aware of how Muslim women may feel, and their fears around speaking out. </p>
<p>Without this awareness, Muslim women will continue to go through the routine notions of engaging with healthcare services without getting optimal care that acknowledges their needs. And in the case of pregnant women, this could easily impact upon the health of both mother and baby.</p><img src="https://counter.theconversation.com/content/101768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Supported by the National Institute for Health Research (NIHR)
Collaboration for Leadership in Applied Health Research and Care North
West Coast (NIHR CLAHRC NWC). The views expressed are those of the authors and not necessarily those of
the NHS, NIHR or Department of Health and Social Care. </span></em></p>Muslim women in the UK don’t feel able to discuss their healthcare needs because of fears of islamaphobia.Shaima Hassan, Research Associate , University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1056102018-11-07T09:47:55Z2018-11-07T09:47:55ZThe arts are a shadow health service – here’s why<figure><img src="https://images.theconversation.com/files/243224/original/file-20181031-76413-zu8wnx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-bright-beautiful-young-woman-art-271542965?src=ZBdg00Q1p58ae2NdIOlCtA-1-5">Mike Orlov/Shutterstock.com</a></span></figcaption></figure><p>The UK’s Health Secretary, Matt Hancock, has said that doctors should prescribe dance classes and trips to concert halls as well as pills and physio – and set out plans to make this “<a href="https://www.bbc.co.uk/news/entertainment-arts-46111595">social prescribing</a>” a reality. He clearly gets how the arts can benefit health and well-being. But there is more to do. The health benefits to be gained from creative practice are enormous and universal – and so need widespread investment.</p>
<p>People tend to think of personal health in a limited way. Medical services of one kind or another are largely given the onus of keeping people well and fixing them when they become poorly. We are encouraged to stop smoking, drink less alcohol, lose weight and exercise. More recently, the idea of well-being has helped to shift that somewhat. Yoga and mindfulness, to take two examples, are now heavily associated with the idea of health.</p>
<p>But rarely, if at all, are people encouraged to take up creative hobbies: the arts do not tend to be thought of in medical terms. But creative practices in the arts and humanities really can help people stay healthy or recover when illness strikes. By engaging in creative activities such as music making and listening, dance, drawing, comedy, reading groups, visiting museums and galleries and so on, people can do their minds and bodies the world of good. The arts can therefore be thought of as the shadow health service. They can improve our physical and mental health, not least through the increased social connections they generate.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=463&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=463&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244069/original/file-20181106-74760-ry9cz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=463&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dancing to health.</span>
<span class="attribution"><span class="source">Eugene Titov/Shutterstock.com</span></span>
</figcaption>
</figure>
<p>Creative practice has <a href="http://www.artshealthandwellbeing.org.uk/resources/research">documented potential</a> for advancing health and well-being. Indeed, some arts and expressive therapies, such as art therapy, music therapy, movement or dance therapy, poetry therapy and psychodrama, are already <a href="https://www.psychologytoday.com/gb/blog/arts-and-health/201710/expressive-arts-therapy-and-the-arts-in-health">well established</a> in health services.</p>
<p>Over the last ten years, <a href="https://www.evidence.nhs.uk/search?q=arts+and+health">research</a> has demonstrated the importance of creative practice in the arts and humanities. They can help maintain health, provide ways of breaking down social barriers and expressing and understanding experiences and emotions, and assist in developing trust, identities, shared understanding and more compassionate communities. So, hopefully, this sidelining of the arts in health terms is changing. </p>
<h2>Drumming and dancing</h2>
<p>In 2017, the UK government published <a href="http://www.artshealthandwellbeing.org.uk/appg-inquiry/Publications/Creative_Health_Inquiry_Report_2017_-_Second_Edition.pdf_">a report</a> on the compelling case of how creative practices can transform health and well-being. A <a href="http://www.healthhumanities.org/creative_practice_mutual_recovery/">programme of research</a> that I directed contributed to this body of evidence. In this five-year programme, we measured mental health and well-being benefits for <a href="http://cpmr.mentalhealth.org.uk/">a range of creative activities</a>. Particularly compelling new evidence emerged in the <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151136">group drumming project</a>, which found that it can reduce depression and anxiety and improve social resilience in mental health service users.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244068/original/file-20181106-74772-1k6ov9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A group drumming workshop.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-people-playing-on-drums-therapy-314929814?src=EwS1dkbYBw-mAkMcb4yPIA-1-0">Lightpoet/Shutterstock.com</a></span>
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<p>It is not just people with specific health conditions who can benefit from creative resources and practices. The evidence of clear benefits for health and well-being more generally is now robust in relation to a wide array of creative practices such as <a href="http://www.ox.ac.uk/research/choir-singing-improves-health-happiness-%E2%80%93-and-perfect-icebreaker">singing in choirs</a>, listening to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3740599/">particular kinds of music</a>, engaging in the <a href="https://www.artscouncil.org.uk/sites/default/files/download-file/power_of_art_visual_arts.pdf">visual arts</a>, <a href="https://www.pdsw.org.uk/wp-content/uploads/2018/04/Breathe-Commissioning-Dance-for-Health-Wellbeing-Guide-for-Commissioners-by-Jan-Burkhardt-2012.pdf">dancing</a>, <a href="https://readingagency.org.uk/adults/quick-guides/reading-well/">reading or joining reading groups</a> and <a href="https://museumsandwellbeingalliance.files.wordpress.com/2015/07/museums-for-health-and-wellbeing.pdf">gallery or museum visiting</a>.</p>
<p>The creative arts and humanities are one of the best ways to enhance public health and social connectedness. More than this, these resources do not need to be prescribed by a doctor. The public can access for themselves a shadow health service of creative facilities and resources to buffer themselves against the hard knocks of life, recover from illness or improve quality of life despite illness or poor health.</p>
<h2>A world without song?</h2>
<p>Just imagine for a moment a world robbed of facilities, resources and activities in the creative arts and humanities: no music, no singing, no art, no stories to read or share, no dancing, no theatre, no film, no galleries or museums, no crafts. It should be clear that health and well-being would be difficult to attain. A short reflection on such a horrifying prospect brings home just how much we would miss them. It is easier and more inspiring to recognise them as a second national health service.</p>
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<img alt="" src="https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/244067/original/file-20181106-74757-5at78o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A form of therapy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-paint-cans-colors-colorful-arranged-518013877?src=ejyS4ipVISu24BBbocr01w-1-4">Sanit Fuangnakhon/Shutterstock.com</a></span>
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<p>In the UK, there is constant criticism of the way that public funding for the arts tends to favour <a href="https://www.theguardian.com/culture/2016/dec/15/public-funding-for-arts-still-skewed-towards-london-report-says">London over other regions</a>. There are also ever-looming spending cuts, not least to <a href="https://www.ft.com/content/e1b325ce-122f-11e8-940e-08320fc2a277">museums and galleries</a>, and myriad challenges to funding in a <a href="https://www.artscouncil.org.uk/sites/default/files/download-file/Funding%20Arts%20and%20Culture%20in%20a%20time%20of%20Austerity%20(Adrian%20Harvey).pdf">period of austerity</a>, as there are in many other countries. In the UK and elsewhere, it’s time for governments to take the arts and humanities more seriously as a cost effective, national asset that impacts on the health and well-being of a nation. </p>
<p>Why shouldn’t governments strive towards a National Health Humanities Service (NHHS) that works strategically alongside health and social care services, helping to unblock queues to see GPs, complementing traditional medical interventions, and transforming care environments in our hospitals, the community or people’s homes? Why leave the arts and humanities on the fringe – as merely ornamental or decorative? They deserve more than being left on a funding drip-feed.</p><img src="https://counter.theconversation.com/content/105610/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Crawford receives funding from Arts Humanities Research Council. </span></em></p>Dancing, drumming, visiting galleries and so on are one of the best ways of enhancing public health.Paul Crawford, Professor of Health Humanities, University of NottinghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/917512018-07-31T20:15:28Z2018-07-31T20:15:28ZWhen is it OK to call an ambulance?<p>When would you call 000 for an ambulance? When a fall results in a nasty fracture? Concern that labour is progressing so rapidly that you’ll give birth before you can get to hospital? Weakness from prolonged vomiting and diarrhoea? </p>
<p>If you take a look at some <a href="http://www.ambulance.nsw.gov.au/Calling-an-Ambulance/When-to-call-Triple-Zero-000.html">Australian ambulance websites</a>, none of these examples meet their definition of a “medical emergency” suitable for an ambulance response. But that doesn’t mean you shouldn’t call for an ambulance in these situations.</p>
<p>In <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health/ambulance-services">2016-17</a>, Australian ambulance services attended 3.5 million incidents. These include cases categorised as urgent but not a “lights and sirens” response, as well as transport between hospitals and other health facilities. Only 1.1 million of the incidents, or approximately 37%, were classified as emergencies. </p>
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Read more:
<a href="https://theconversation.com/paramedics-need-more-support-to-deal-with-daily-trauma-97315">Paramedics need more support to deal with daily trauma</a>
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<h2>What happens when you call 000?</h2>
<p>When someone calls the emergency number and asks for an ambulance, the call-taker typically takes the caller through a computer-based script. They attempt to define the health problem, and determine the response required: lights and sirens, or not.</p>
<p>Call-takers are not medically trained, but use a call screening program to identify the health problem. This system includes non-urgent categories such as “sick person”, which includes complaints such as an earache, sore throat and hiccups.</p>
<p>People may find it easiest to call 000 for a broad range of health problems, particularly after hours. But the deployment of paramedics for non-urgent health problems reduces their availability to respond to medical emergencies and major incidents.</p>
<h2>Where are we going wrong?</h2>
<p>Media campaigns have been used to educate the public about when it’s appropriate to call an ambulance. Strategies such as the Ambulance Victoria <a href="https://www.ambulance.vic.gov.au/community-education/ambulances-are-for-emergencies/">Ambulances are for Emergencies</a> campaign includes stories of lives saved that may have been lost had ambulances been tied up with non-emergency calls.</p>
<p>Health promotion bodies have also highlighted the types of problems that should be considered health emergencies: chest pain, breathing difficulty, altered level of consciousness, sudden numbness, or paralysis of the face or limb.</p>
<p>But attempts to define a “health emergency” often fail to appreciate that the definition is dynamic and depends on context. A complaint of weakness associated with prolonged vomiting and diarrhoea may not be an emergency when you have family support and transport options. But it may be an emergency when the patient is an elderly person living alone without support. </p>
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<img alt="" src="https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229929/original/file-20180731-176698-9fk08.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Patients who arrive at hospital by ambulance are likely to believe their condition is more serious than if they got there themselves.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-team-working-on-patient-emergency-168769238?src=CRCnZ-2UKKWBIUb0mQBTmg-1-4">Shutterstock</a></span>
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<p>There is also a difference between the patient’s perception of a health emergency and a health professional’s definition. This has been investigated by an <a href="http://www.publish.csiro.au/ah/AH10922">Australian study</a> that found patients cannot be expected to accurately evaluate the urgency of a health event. Social and emotional cues are often used to identify medical urgency. Understandably, people may be poorly placed to make rational, informed decisions about care options during a health crisis.</p>
<p>Research on ambulance use in Queensland <a href="http://onlinelibrary.wiley.com/doi/10.1111/acem.12149/full">aimed to understand</a> why people use ambulance services for minor health problems. It found that people who arrived at an emergency department by ambulance had a higher self-reported perception of the seriousness or urgency of their problem than patients who self-presented to hospital emergency departments. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a>
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<p>The ambulance users were more likely to believe that ambulance services were for everyone to use, irrespective of the severity of their condition. They were also more likely to believe that arriving by ambulance would lead to priority treatment at the hospital.</p>
<p>One possible explanation for these findings relates to health literacy. Poor health literacy affects the person’s ability to interpret health advice and navigate the health system to identify options for unscheduled care. Low levels of health literacy also limit the effectiveness of interventions that are designed to change behaviour. </p>
<p>Research from the <a href="https://www.pc.gov.au/inquiries/completed/productivity-review/report">Productivity Commission</a> found the majority of Australians have inadequate health literacy. The proportion is greatest for those with chronic conditions. Even 40% of people with a health-related qualification have inadequate health literacy.</p>
<h2>Where can we improve?</h2>
<p>Taking into account the difficulties of making crucial decisions during a crisis situation, there are a number strategies which may facilitate more effective use of ambulance resources.</p>
<p>One alternative approach is to use experienced clinicians to screen emergency calls and direct the caller to the most appropriate health pathway.</p>
<p>Several Australian ambulance services have introduced such a system, and the outcome of this screening process may be to dispatch an ambulance, or initiate a home visit by a doctor, nurse or paramedic trained to manage non-urgent health problems. </p>
<p>These systems have been shown to provide <a href="http://www.publish.csiro.au/ah/ah15134">effective referral options</a> for cases that don’t represent medical emergencies. Instead of discouraging people to call 000, they use call screening systems to identify emergency cases, which may include those not explicitly listed on ambulance service websites.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-the-future-your-ambulance-could-be-driverless-78974">In the future your ambulance could be driverless</a>
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<p>If you you’re confident navigating health information, you may find sites such as <a href="https://www.healthdirect.gov.au/">healthdirect</a> useful. This service uses a web-based algorithm to question the user about the nature of the health problem to direct the patient to local health services based on the nature of the complaint. It also provides a national phone number to contact a registered nurse about your health problem. </p>
<p>But if you’re unsure whether an ambulance is required, it’s OK to call 000 for advice. After all, delaying a call for a serious health problem can lead to a catastrophic outcome.</p><img src="https://counter.theconversation.com/content/91751/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Lord has received funding from the Office for Learning and Teaching Innovation and Development grant: Expert in my pocket: a mobile-enabled repository of learning resources for the development of clinical skills in student health professionals. (Ref: ID13-2962). $180,000.</span></em></p>If you’re unsure whether you need an ambulance, it’s OK to call 000 for advice.Bill Lord, Associate Professor in Paramedicine, University of the Sunshine CoastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/951632018-05-15T13:23:35Z2018-05-15T13:23:35ZProviding healthcare to men who have sex with men is complex but possible<figure><img src="https://images.theconversation.com/files/218244/original/file-20180509-34009-14z8zzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There needs to be a wide range of sexual health services for men who have sex with men.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Research has shown that addressing HIV in certain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228373">key populations</a> is a priority in order to end the epidemic in the general population.</p>
<p>Key populations are groups identified by the World Health Organisation that warrant specific attention in health programmes because they face a particularly high risk of getting HIV and other sexually transmitted infections. They are also marginalised and do not have good access to health services. </p>
<p>One of these groups is men who have sex with men (MSM). It is critical to ensure that they are able to get access to HIV prevention and treatment services. </p>
<p>But in many parts of sub-Saharan Africa, including South Africa, men who have sex with men <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780345/">encounter stigma and prejudice</a> when they use health services. This often limits their access to healthcare. </p>
<p><a href="http://journals.lww.com/stdjournal/Abstract/publishahead/Utilization_of_Sexually_Transmitted_Infection.98418.aspx">Our research</a> shows that it’s possible to provide good quality care in the public sector to men who have sex with men.</p>
<p>We looked at health services specifically designed and provided at a set of South African government clinics. We found that men who accessed these services did well on antiretroviral regimens. </p>
<h2>South Africa’s reality</h2>
<p>An estimated <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">7.1 million people in South Africa are living with HIV</a>. That’s about 12.6% of the general population. </p>
<p>Among men who have sex with men, this figure <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/age-bias-in-survey-sampling-and-implications-for-estimating-hiv-prevalence-in-men-who-have-sex-with-men-insights-from-mathematical-modelling/A301257CE75A110D4BD61594764A8E98">may be as high as 34.6%</a>. </p>
<p>Providing health services to this group is challenging partly because of its diversity. Many men who have sex with men do not see themselves as gay. They may identify as bisexual or straight, or not label themselves in this way at all. This makes it difficult to find ways to reach out to them. </p>
<p>Their sexual practices also vary which can increase their risk of contracting HIV. For example, some men have anal sex without a condom, which is risky. But not all men who have sex with men have anal sex. </p>
<p>So sexual health services for men who have sex with men need to understand and meet the needs of a wide range of men. The challenge is that they usually have to access regular health services where they feel they are not understood and experience discrimination. They often feel unable to explain their sexual history to health workers. </p>
<p>Our study looked at how a health service targeted at men who have sex with men, <a href="http://www.health4men.co.za/sexual-health-services/">Health4Men clinics</a>, provided by an NGO in government run, primary care health facilities could help to solve these problems. </p>
<p>There are three Health4Men clinics in Johannesburg and one in Cape Town. They provide comprehensive sexual health services, including preventing and treating HIV and other sexually transmitted infections. </p>
<h2>Filling the gaps</h2>
<p>Of the gay and bisexual men who were tested for HIV at the clinics close to 40% were HIV positive. The figure was 14% for straight men. </p>
<p>We found that the clinics were very successful in helping men remain on antiretroviral treatment. More than 80% of the men who started antiretroviral treatment at the clinics were still taking their medication two years later. There was no difference in the retention patterns between gay and straight men. </p>
<p>People on antiretroviral therapy must take treatment for the rest of their lives. But keeping people on treatment is a challenge.</p>
<p>In addition, men who have sex with men are often unaware of their sexually transmitted infections because there often aren’t visible symptoms. This often means that they don’t seek treatment. Finding and treating these infections is important because untreated sexually transmitted infections increase the risk of contracting HIV. </p>
<p>Part of the reason that Health4Men services have been successful is the presence of male health care workers. They are specially trained to be sensitive to diversity in gender and sexuality, and to understand the specific needs and health problems affecting men who have sex with men. Their presence seems to make many men feel more comfortable discussing sexual matters. </p>
<p>And based on our research, the clinics attracted men who identified as gay, bisexual and straight, showing that they were considered safe spaces. </p>
<h2>Meeting the needs</h2>
<p>To stop the spread of HIV, South Africa needs to expand access to specialised health services for men who have sex with men. Services should also be provided in community spaces linked to health facilities. </p>
<p>Implementing these specialised services in rural areas is a bit more challenging due to limited resources. But in these areas health workers should be trained to understand diversity in gender and sexuality. Training health workers about diversity has been shown to reduce prejudicial <a href="https://www.ncbi.nlm.nih.gov/pubmed/27835058">attitudes toward men who have sex with men</a>.</p>
<p>In the end, what is important is that HIV prevention services – including regular testing, access to condoms and lubricant, treatment of sexually transmitted infections and PrEP (a pill taken daily to prevent HIV infection) – reach HIV-negative men who have sex with men. It’s also crucial for those who are already HIV-positive to have access to antiretroviral therapy to decrease the spread of HIV.</p><img src="https://counter.theconversation.com/content/95163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Rees works for Anova Health Institute. </span></em></p><p class="fine-print"><em><span>Remco Peters works for the Anova Health Institute</span></em></p>In many parts of sub-Saharan Africa men who have sex with men encounter stigma and prejudice when accessing health services.Kate Rees, Honorary Research Associate, Public Health Medicine, University of Cape TownRemco Peters, Extraordinary Professor in the Department of Medical Microbiology, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/801762017-06-29T10:14:24Z2017-06-29T10:14:24ZUK policy turns people with learning disabilities into commodities, study reveals<figure><img src="https://images.theconversation.com/files/176189/original/file-20170629-16069-ikdy0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There are well over <a href="https://www.gov.uk/government/publications/people-with-learning-disabilities-in-england-2015">a million people</a> with learning disabilities in England. Like anyone, people with learning disabilities or autistic people can experience times of crisis and heightened distress, particularly when they and their families have not had the support they need.</p>
<p>These people, their families, the government and health services agree what the best help is at times of crisis. It is help that is at home or close to home, keeps people connected to who and what they know, and that is respectful and geared towards helping the person pursue a fulfilling life. The kind of help that anyone would want for themselves or a loved one.</p>
<p>But this is not what they are getting. <a href="http://wp.lancs.ac.uk/cedr/7daysofaction2017/">Our new report</a> from the 7 Days of Action campaign group and Lancaster University reveals that private companies are being paid over a quarter of a billion pounds a year by the NHS to run “specialist inpatient units” or mini-hospitals for autistic people or people with learning disabilities in crisis. These companies are building new inpatient units when government policy for the last five years has been to reduce them, as they are not the best way to support people in crisis. Private companies now run half of all these services in England.</p>
<h2>Transforming care</h2>
<p>Six years ago, a BBC Panorama <a href="http://www.bbc.co.uk/news/uk-england-bristol-20078999">undercover documentary</a> exposed horrendous abuse of autistic people or those with learning disabilities in Winterbourne View, run by a private company, Castlebeck. Winterbourne View was one of this network of inpatient units supposed to provide highly expert support to people in crisis, with the aim of helping them get back to living their lives as quickly as possible. These units are paid for with NHS money, but can be run by the NHS or by private companies. Six care staff at Winterbourne View <a href="http://www.bbc.co.uk/news/uk-england-bristol-20092894">were jailed</a> and five further staff were given suspended sentences for their part in the abuse, and the <a href="http://www.bbc.co.uk/news/uk-england-bristol-20078999">unit was closed</a>.</p>
<p>In reality, many of these inpatient units don’t do what they are supposed to. According to people’s care plans written by health service professionals, <a href="http://digital.nhs.uk/catalogue/PUB30007">almost a third of people</a> in these units don’t need to be there. And over <a href="http://digital.nhs.uk/catalogue/PUB30007">a third</a> have been in them for five years or longer. <a href="http://content.digital.nhs.uk/catalogue/PUB19428">A 2015 census</a> of those in these units found that, in the three months before the census, almost a quarter had been a victim of physical assault in the unit.</p>
<p>Appalling episodes of abuse in these units <a href="http://www.challengingbehaviour.org.uk/cbf-articles/latest-news/c4dispatches.html">continue to be exposed</a>, including basic failures of care resulting in people <a href="http://justiceforlb.org/">dying a preventable death</a>. <a href="https://www.sevendaysofaction.net/">People with learning disabilities</a> repeatedly talk about how inpatient units are not the best place for them and how, once admitted to a unit, they find it very hard to get out.</p>
<p>The government agrees. Ever since the BBC Panorama programme, <a href="https://www.gov.uk/government/publications/winterbourne-view-hospital-department-of-health-review-and-response">government policy in England</a> has been to drastically reduce the number of these inpatient units, including plans to improve how people and families are <a href="https://www.england.nhs.uk/learning-disabilities/natplan/">supported in their own homes</a> so that people are less likely to experience a crisis and are more likely to get support at home if they do.</p>
<p>But not nearly enough has been done. There are arguments about whether the number of autistic people or people with learning disabilities in these inpatient units has gone down and by how much. But on any given day, there are between <a href="http://www.digital.nhs.uk/catalogue/PUB30000">2,500 and 3,000 people</a> in these “specialist” units. At least another 1,000 are likely to be in <a href="http://www.digital.nhs.uk/catalogue/PUB30000">general mental health inpatient units</a>. </p>
<p>This isn’t the scale of change set by the government in successive targets, or that demanded by patients and families. Funding these units is also approaching <a href="http://content.digital.nhs.uk/catalogue/PUB19428">half a billion pounds per year</a> of public money that could be invested in much better ways to support people.</p>
<h2>A trade in people</h2>
<p>Given that this has been the clear direction of government policy for at least five years, why haven’t services to support autistic people or people with learning disabilities transformed accordingly? </p>
<p>There are many potential reasons, but one important one is the growth of mostly for-profit private sector inpatient units. This is highlighted in <a href="https://www.sevendaysofaction.net/our-campaigns/a-trade-in-people/a-trade-in-people/">our new report</a>. While the number of inpatient units run by the NHS is falling in line with government policy, the number of inpatient units run by the private sector is increasing. In 2006, a fifth of units were run by the private sector, now it is up to around a half. More than £250 million of public money per year is now spent on these private sector units.</p>
<p>This is a problem because when direct comparisons between NHS and private sector units have been made, <a href="http://webarchive.nationalarchives.gov.uk/20160704150527/http://www.improvinghealthandlives.org.uk/publications/year/2012">private sector units were revealed to be worse</a>. They were <a href="http://webarchive.nationalarchives.gov.uk/20160704150527/http://www.improvinghealthandlives.org.uk/publications/1078/A_Review_of_the_Results_of_the_2011/12_Focused_CQC_Inspection_of_Services_for_People_with_Learning_Disabilities">less likely to comply with standards</a> set by the health service regulator, people stayed in them longer, and people in them were more likely to experience episodes of <a href="http://webarchive.nationalarchives.gov.uk/20160704150527/http://www.improvinghealthandlives.org.uk/publications/1161/A&T_and_other_specialist_inpatient_care_for_people_with_LD_in_the_Count-Me-In_census">assault, self-harm, physical restraint from staff, and seclusion</a> (being placed in solitary confinement for a period of time)</p>
<p>Private sector units also charge the public purse more. New units are not being built to be close to those people using them, with decisions about them likely to be based on financial considerations for the company. A quarter of people in these units are <a href="http://digital.nhs.uk/catalogue/PUB30007">over 100 kilometres from home</a>, wrenching people away from family and friends and making it very difficult and expensive for families to visit regularly.</p>
<p>Under financial pressure, the temptation is for councils (who pay for social care) and health service commissioners to try and shunt people (and therefore costs) between them rather than work together to develop decent support for people and families.</p>
<p>The result is people in crisis being sent to any inpatient unit with an available place, at short notice. Private companies operate on the Kevin Costner Field of Dreams <a href="https://en.wikipedia.org/wiki/Field_of_Dreams">principle</a> – if you build it, they will come. Without action explicitly designed to stop this happening, this trend will only continue, with more and more people turned into commodities.</p><img src="https://counter.theconversation.com/content/80176/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Hatton receives funding from the National Institute for Health Research and Public Health England, although the views expressed in this article are personal. He is affiliated with the 7 Days Of Action campaign group. </span></em></p>Private companies are building new inpatient units – the state has been trying to reduce them for the last five years.Chris Hatton, Professor of Psychology, Health and Social Care, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/657512017-05-03T16:01:20Z2017-05-03T16:01:20ZHow Boko Haram is devastating health services in North-East Nigeria<figure><img src="https://images.theconversation.com/files/167715/original/file-20170503-21630-se8k1n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children at a camp for people displaced by Boko Haram insurgents in North-East Nigeria. </span> <span class="attribution"><span class="source">Flickr/Immanuel Afrolabi</span></span></figcaption></figure><p><em>Several towns in the north-eastern region of Nigeria have been overrun by Boko Haram militants, who are engaged in <a href="https://africacheck.org/factsheets/factsheet-explaining-nigerias-boko-haram-and-its-violent-insurgency/">violent clashes</a> with authorities. Millions have been displaced and in May 2013, Nigeria declared a state of emergency in Borno, Yobe and Adamawa. Health services in the region have been severely affected. Felix Obi and Ejemai Eboreime shed light on the situation.</em> </p>
<p><strong>Which areas are being affected by Boko Haram and how many people are at the centre of it?</strong></p>
<p>The Boko Haram insurgency, which began in 2009, has mostly affected people living in Nigeria’s north-eastern states. One of them Borno state has been at the epicentre of the insurgency. </p>
<p>To date more than 20,000 people have been killed and over 2 million people have fled their homes. There are over <a href="http://www.unocha.org/nigeria/about-ocha-nigeria/about-crisis">7 million people</a> in need of humanitarian assistance in Borno, Yobe and Adamawa states – and more than half are children. </p>
<p><strong>What effect is this having on health services?</strong></p>
<p>Even before the insurgency, North-East Nigeria had some of the worst health and <a href="https://www.humanitarianresponse.info/system/files/documents/files/pine-_the_north_east_err_plan_-_full_-_pine_-_july_2015_2015_2020.pdf">socioeconomic indices</a> in the country. This is against the backdrop of a weak health system marked by inadequate health facilities and a dearth of skilled health workers. There’s also little donor support compared with other regions of Nigeria. </p>
<p>The insurgency has compounded these problems and also disrupted what health services there were. </p>
<p>Insurgents have destroyed about 788 health facilities in the region. In Borno 48 health workers have been killed and over 250 injured. The state has lost up to 40% of its facilities and <a href="http://www.reuters.com/article/us-nigeria-security-who-idUSKBN1431IM">only a third</a> of those left in Borno state remain functional. </p>
<p>Attrition rates of health workers have also played a role. Over the past two years Borno state has lost <a href="http://leadership.ng/news/480463/insurgency-28-health-workers-killed-445-facilities-destroyed">35% of its doctors</a> to other states. </p>
<p>Insecurity in the areas occupied by the insurgents also make planning and delivering essential health interventions difficult. Resources in camps for internally displaced people have been overstretched, with humanitarian agencies providing most of the health services.</p>
<p><strong>What impact has this had on people?</strong></p>
<p>There are several health consequences. Over 2 million people have been displaced due to the conflict and live in camps for internally displaced people scattered across the North-East Nigeria. Some have gone as far as Abuja and beyond to southern states like Edo. </p>
<p>Overcrowding and poor hygiene in the camps have made them potential spots for <a href="http://www.msf.org/en/article/nigeria-cholera-spreads-displaced-persons-camps-borno-state">recurrent outbreaks of diseases</a> like cholera. There are also many cases of acute malnutrition. Deaths from <a href="http://reliefweb.int/report/nigeria/nutrition-and-food-security-surveillance-north-east-nigeria-emergency-survey-final">malnutrition</a> occur frequently. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167718/original/file-20170503-21614-615co0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A camp for people displaced by Boko Haram insurgents in North-East Nigeria.</span>
<span class="attribution"><span class="source">Flickr/Immanuel Afrolabi</span></span>
</figcaption>
</figure>
<p>And two years after Nigeria celebrated its last case of polio in 2014, <a href="http://www.who.int/mediacentre/news/releases/2016/nigeria-polio/en/">new cases of the disease</a> had resurfaced in the region. This is due to the fact that insurgents occupying villages and towns prevented the polio vaccine being brought into the area. </p>
<p>There has been an outbreak of the <a href="http://www.ncdc.gov.ng/news/67/meningitis-outbreak-in-nigeria-affects-five-states">Cerebrospinal Meningitis epidemic</a> in north west Nigeria in the states of Zamfara, Sokoto, Kebbi, Katsina and Niger. There are fears that the epidemic could spread to the North-East Nigeria because the health system is so fragile.</p>
<p><strong>What are the long-term consequences?</strong></p>
<p>One direct health consequence will be an increase in infant and maternal mortality cases. But there will also be a range of other socio-economic consequences that will affect people’s health. These include:</p>
<ul>
<li><p>the disruption in agricultural activities means that food insecurity has worsened which obviously has consequences on peoples’ health</p></li>
<li><p>a plunge in access to education, particularly for girls. Research has shown that there’s a link between women’s education levels and <a href="https://www.scientificamerican.com/article/graphic-science-female-education-reduces-infant-childhood-deaths/">infant and maternal mortality</a>. </p></li>
<li><p>worsening poverty and inequality in what is already one of <a href="https://www.proshareng.com/news/Nigeria%20Economy/Nigerian-Poverty-Profile-Report-2010---NBS/16302">Nigeria’s most impoverished regions</a></p></li>
<li><p>financial implications. The massive destruction of homes and social amenities means that the government will be faced with rebuilding infrastructure, while individual households grapple with rebuilding communities. </p></li>
</ul>
<p><strong>What is the Nigerian government doing to rebuild the north-east’s health system?</strong></p>
<p>The government has flagged several initiatives to rebuild the health systems of the affected states in the North-East Nigeria. This includes the <a href="https://www.humanitarianresponse.info/system/files/documents/files/pine-_the_north_east_err_plan_-_full_-_pine_-_july_2015_2015_2020.pdf">Presidential Initiative for the North East</a>, an economic redevelopment plan for affected states.</p>
<p>Nigerian President Muhammadu Buhari has been eager to reconstruct the area and launched a <a href="https://pcni.gov.ng/the-buhari-plan/">plan</a> that includes resuscitating health services. The plan estimates that the cost of damaged health facilities is about US$ 147 million. The reconstruction process will require huge investments over the short and long-term. </p>
<p>The government also plans to use <a href="http://leadership.ng/news/566945/gff-approves-20m-for-reproductive-health-in-north-east-nigeria">US$ 20 million from the Global Financing Facility</a> to support essential services in the north east. The <a href="https://www.globalfinancingfacility.org/introduction">Global Financing Facility</a> partnership is a World Bank and United Nations initiative that finances interventions to improve the health of women, children, and adolescents in a country.</p>
<p>There are also efforts to expand the <a href="http://projects.worldbank.org/P120798/nigeria-states-health-program-investment-credit?lang=en&gclid=CLvL-bq9ttMCFcYV0wodbuAIAw">Nigeria State Health Investment Project</a> – another World Bank supported initiative which encourages the delivery and use of maternal and child health interventions and improve the quality of care at health facilities – to the remaining north-east states. </p>
<p>It remains to be seen how these initiatives will significantly change the health landscape and reverse North-East Nigeria’s poor health indices.</p><img src="https://counter.theconversation.com/content/65751/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More than 788 health facilities have been destroyed in parts of North-Eastern Nigeria captured by Boko Haram insurgents, crippling health services in the area.Felix Abrahams Obi, Research Fellow/Research Uptake Officer of the Health Policy Research Group, University of NigeriaEjemai Eboreime, PhD fellow in Implementation Science, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/619722016-07-06T10:18:39Z2016-07-06T10:18:39ZHow the 2003 Iraq invasion devastated the country’s health service<p>Thirteen years ago, American and British troops launched Operation Iraqi Freedom. The Iraqis were promised freedom from tyranny, but the subsequent destruction of the Iraqi state apparatus as well as the cycle of violence that continues to this day destroyed the health system that cared for the nation. </p>
<p>In 2003, the health service in Iraq was in a bad way following years of economic sanctions imposed by the United Nations. The sanctions contributed to the <a href="https://www.theguardian.com/theguardian/2000/mar/04/weekend7.weekend9">death of thousands of citizens</a> from malnutrition and a lack of essential drugs. </p>
<p>This fragile, state-sponsored health service was severely damaged by the invasion. <a href="http://bit.ly/29q79ow">Around 7%</a> of the hospitals were partly destroyed during the war, and <a href="http://mondediplo.com/2007/02/04iran">12% were looted</a> in the chaos that followed. Many health care facilities were taken over <a href="http://www.rand.org/pubs/monographs/MG321.html">for military use</a> during the conflict. </p>
<h2>No plan to rebuild what they’d destroyed</h2>
<p>Neither the Americans nor the British had any plans for the healthcare system. Despite a promised aid package of <a href="http://www.rand.org/pubs/monographs/MG321.html">$18.4 billion</a>
to rebuild Iraq, only a few small contracts were awarded to private contractors. The World Health Organisation (WHO), United Nations International Children’s Emergency Fund (UNICEF) and local Iraqi experts were not consulted. The main aim of these contracts was to train the ministry of health staff on public health planning and health policy development since the majority of the experienced staff were made redundant as part of the American policy to rid the government institutions of people likely to be loyal to the previous regime. </p>
<p>Iraq, to this day, has no comprehensive health policy. Contrast this with the Iraqi health service of the 1970s and 80s which was one of the <a href="http://eprints.lse.ac.uk/59519/1/__lse.ac.uk_storage_LIBRARY_Secondary_libfile_shared_repository_Content_Cetorelli%2C%20V_Expansion%20health%20facilities_Cetorelli_Expansion%20health%20facilities_2014.pdf">most advanced in the Middle East</a>. </p>
<p>Today, most of the country’s 1,717 primary healthcare centres have <a href="http://www.who.int/hac/crises/irq/background/Iraq_Health_in_Iraq_second_edition.pdf">no running water or electricity</a>, and the <a href="http://www.who.int/hac/crises/irq/background/Iraq_Health_in_Iraq_second_edition.pdf">197 hospitals</a> don’t have enough equipment or expertise to deal with the needs of a nation confronting ever increasing violence and terrorism. </p>
<p>After the handover of the power from the US-led coalition forces to the first Iraqi government, it was reported that 40% of the 900 essential drugs were <a href="http://www.washingtonpost.com/wp-dyn/content/article/2006/09/16/AR2006091600193.html">out of stock</a> in hospitals. This happened at time when Iraq needed every little bit of help it could get to deal with its worst health crisis for decades. There was – and still is – a <a href="http://www.who.int/hac/crises/irq/iraq_phra_24october2014.pdf?ua=1&ua=1">continuous surge</a> in trauma-related hospital admissions caused by the violence in addition to an increase in the burden of chronic diseases such as heart disease and cancer (making up to 44% of the causes of mortality).</p>
<p>Last year, a <a href="http://applications.emro.who.int/dsaf/EMROPUB_2015_EN_1904.pdf?ua=1&ua=1">WHO report</a> revealed the dark reality of the state of health in Iraq with high mortality rates among children under the age of five as well as outbreaks of diseases such as cholera and polio, in a country where millions of people have no access to healthcare services. </p>
<h2>Exodus</h2>
<p>The poor security conditions that continue to this day and the failure of the Anglo-American occupation forces to come up with a policy to protect the healthcare professionals led to an exodus, with nearly 75% of doctors, pharmacists and nurses <a href="http://www.rand.org/pubs/monographs/MG321.html">leaving their jobs since 2003</a> with many departing to seek refuge in safer countries. </p>
<p>It is estimated that as few as 9,000 doctors and 15,000 nurses are serving nearly 28m Iraqis. This is nearly six doctors and 12 nurses for every 10,000 citizens. For a similar population in the UK, there are 23 doctors and 88 nurses that <a href="http://apps.who.int/gho/data/node.country.country-IRQ?lang=en">provide healthcare services</a>. Dentists, pharmacists and healthcare managers are also in short supply. </p>
<p>There are almost no healthcare professionals in rural areas or to provide care for millions of <a href="https://www.icrc.org/eng/resources/documents/update/2011/iraq-update-2011-12-14.htm">internally displaced people</a>. Also, training of healthcare workers was disrupted with medical and nursing schools struggling to remain open and many students facing security threats and no prospect of adequate training. The lack of provisions to train more healthcare professionals and the mass migration of trained staff exacerbated the shortage of experienced well-trained professionals to provide health service. </p>
<p>Any plan to rebuild the healthcare system in Iraq should aim to provide adequate protection for the people providing the service. </p>
<p>The state of the Iraqi health service and the future of its workforce can be summarised in the <a href="http://www.who.int/dg/speeches/2015/iraq-humanitarian-response/en/">words of the WHO Director</a> General, Margaret Chan: “The situation is bad, really bad, and rapidly getting worse.” </p>
<p>Iraq is facing a health and humanitarian crisis as the result of decades of war, occupation, violence and terrorism. Nearly 3m people are internally displaced, 6.9m Iraqis need immediate access to essential health services, and 7.1m need urgent access to clean water and sanitation. As the Chilcot Inquiry finally releases it report into the war, people in Iraq continue to suffer the results of Operation Iraqi Freedom.</p><img src="https://counter.theconversation.com/content/61972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ahmed Aber does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most of the country’s 1,717 primary healthcare centres have no running water or electricity and the hospitals are ill-equipped and under-staffed.Ahmed Aber, Health Economics Research Associate & Surgical Trainee, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/459052015-09-21T05:29:40Z2015-09-21T05:29:40ZHow forgotten victims of emotional abuse are building new support networks online<figure><img src="https://images.theconversation.com/files/95362/original/image-20150918-17701-4ogvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Home comfort</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Two women are murdered every week in the UK as a result of <a href="http://www.lwa.org.uk/understanding-abuse/statistics.htm">domestic violence</a>. The issue affects one in four women and one in six men at some point in their lives. Domestic violence also has more repeat victims than any other crime and costs the public £23 billion every year. And of those victims who have received hospital treatment for domestic violence injuries, 400 will go on to commit suicide within the year.</p>
<p>Such statistics are shocking, but what they don’t tell us is how many additional victims suffer from <a href="http://www.womensaid.org.uk/domestic_violence_topic.asp?section=0001000100220042&sectionTitle=Emotional+abuse">emotional abuse</a>, which is another form of domestic violence. Emotional abuse is not regarded as a criminal offence in adult relationships but it is just as destructive to victims’ mental health, as a review in <a href="http://www.sciencedirect.com/science/article/pii/S0140673602083368">The Lancet</a> revealed. It affects their self-esteem, emotional well-being, relationships with others and personal freedom. </p>
<p>Emotional abuse features across the entire spectrum of domestic violence. It can take the form of destructive criticism, put-downs and name calling, but also isolation, harassment, monitoring behaviours, and lying to a victim and their friends and family. It may also go hand-in-hand with sexual abuse.</p>
<p>But because emotional abuse is not a “crime”, its victims find it especially difficult to receive protection or even to be taken seriously by others at all. <a href="http://adc.bmj.com/content/95/1/59.full.pdf+html">Research suggests</a> that this may also be because emotional abuse lacks the public and political profile of physical and sexual abuse.</p>
<h2>Limited support</h2>
<p>Unlike victims of these crimes, emotional abuse victims may not seek help because they are unprotected by the law. The government hopes to address this lack of support as it introduces a new <a href="http://www.bbc.co.uk/newsbeat/article/30098611/emotional-abuse-to-become-illegal-under-new-domestic-abuse-law">domestic abuse law</a> later this year. This will criminalise the emotional abuse which underlies many abusive relationships.</p>
<p>Emotional abuse is a common occurrence affecting <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4102.0main+features602014">a fifth of intimate partner relationships</a>. Despite far-reaching effects, there is a surprising <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2810%2961079-3.pdf">lack of research</a> on emotional abuse in adult relationships. At present, emotional abuse does not receive the attention from researchers and health services that it needs to enable victims to be recognised and professionally supported. </p>
<p>So, where do people go to receive the support they so desperately need? If victims are not protected by the law, if they are misunderstood by family and friends, and support from health services is lacking, then to whom do they turn?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95339/original/image-20150918-17689-1c2mysb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Call for help.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Online groups</h2>
<p>In the digital age, one obvious place to look for support is online. Through numerous online forums, “victims” of domestic violence become “<a href="http://www.womensaid.org.uk/page.asp?section=0001000100080021&sectionTitle=Survivors+Forum">survivors</a>” who seek the emotional support from others they lack elsewhere in their lives. As with forums for patients with long-term conditions, these websites offer common components of support. This comes in the form of sharing experiences, seeking and offering advice, comparing coping strategies, and signposting to professional resources, as well as simply letting users know they are not alone.</p>
<p>Another of the more interesting uses of <a href="https://www.psychopathfree.com/content.php">these forums</a> is discussion of the perceived <a href="http://psychcentral.com/personality/">personality disorders</a> of abusers, such as antisocial personality disorder and narcissistic personality disorder. But rather than focusing on the perpetrator’s issues, forum advice commonly concerns the victim’s self-protection. This makes sense because these personality disorders are typically thought to be resistant to professional treatment.</p>
<p>Many of these forums have been created by “expert survivors”. These people have escaped and recovered from emotional abuse, and now aim to support others by sharing their experiences and creating a platform for others to discuss their own. Crucially, alongside nearly all of these forums is some form of psychological education in the form of <a href="http://forums.our-place-online.net/index.php?s=061bbe50691a0c176ad6fb8f7e38f245&act=idx">blog posts</a> or other websites with information about how survivors can be helped in the longer-term.</p>
<h2>Empowering and advising</h2>
<p>There are multiple ways these forums may help victims or survivors of emotional abuse, but further research is needed to explore these mechanisms more fully. It may be that support from an online group validates victims’ experiences and empowers them to safely confront or leave their abusers. They may feel protected by an anonymous online identity as they confide in sympathisers about the abuse, perhaps for the first time.</p>
<p>One way to describe these insightful and empathetic forum users is as “<a href="http://www.sheldonpress.com/books/9781847092762.php">enlightened witnesses</a>”, who help others understand and accept their experiences and regain their independence. And with online forums, this support is instantly available. Advice and coping strategies may help victims rebuild their confidence and increase their self-efficacy. Their self-worth may increase as they realise they are not to blame for the abuse. As well as reducing feelings of isolation, a shared perspective may also develop compassion, friendship and humour.</p>
<p>So how can these “survivor forums” contribute to the services provided by health professionals? As a starting point, they give victims a voice that could help highlight needs unmet by the health service. But they could also give health researchers another way to study the nature, prevalence, language and outcomes of emotional abuse, and the coping and exit strategies survivors find to be most effective.</p><img src="https://counter.theconversation.com/content/45905/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ria Poole does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Online support forums provide emotional help to domestic violence survivors in ways often missed by traditional public services.Ria Poole, Research Associate, School of Social Sciences, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447302015-07-16T14:21:49Z2015-07-16T14:21:49ZIf charities are to deliver more health and social services they’ll need to become better organisations<figure><img src="https://images.theconversation.com/files/88526/original/image-20150715-26319-t1z6td.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Camila Batmanghelidjh and Kids Company: a victim of its own remarkable success. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/56675543@N08/5911343345/in/photolist-a1nbqR">NHS Confederation</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>In a week of Greek tragedies it has also been hard to distinguish the gods from the monsters in civil society. Three recent important stories about charities question the accountability and management of the third sector. </p>
<p>Despite <a href="http://www.kidsco.org.uk/about-us">Kids Company</a> being the most successful organisation working with poor children in the country, the charity’s founder, Camila Batmanghelidjh, took a sustained beating from the Cabinet Office which ended up in a demand for her resignation in return for £3m of a £5m funding shortfall – something she says <a href="http://www.thetimes.co.uk/tto/life/article4494696.ece">she won’t be bullied into doing</a> before her plan to leave next year.</p>
<p>A former government minister <a href="http://www.theguardian.com/society/2015/jul/03/camila-batmanghelidjh-government-briefing-kids-company">was quoted as saying</a> that governments of all colours recognised that the charity’s work is extremely valuable and reached parts of the statutory social care system that others didn’t, there as an “unsatisfactory process where Camila would effectively come in and say ‘I’m about to fold if you don’t give me £5m’. That happened on a regular basis and more often than not the hole was plugged … the charity keeps growing and there’s been no retrenchment. She [Camila] cannot say no.”</p>
<p>Putting aside the irony that welfare cuts are in response to a sudden and massive private banking crisis, it appears that Kidsco is a victim of its own remarkable success. </p>
<p>Then there was the very different case of Turning Point and Ibukun Adebayo, the IT director who <a href="http://www.standard.co.uk/news/london/diana-charity-chief-set-for-payout-after-boss-branded-her-looney-tunes-and-sent-obscene-email-about-her-10371214.html">won her case</a> against the mental health charity for unfair dismissal. This was a sorry tale of old-fashioned discrimination and lack of accountability in which Adebayo discovered, among other things, that she was described by the David Hoare, the charity’s deputy chief executive as “Looney Tunes” in an email to the chief executive. Unlike Adebayo, Hoare continues to work at Turning Point.</p>
<p>And then there was the Daily Mail’s <a href="http://www.dailymail.co.uk/news/article-3154251/Now-charities-forced-action-cold-calling-Bosses-agree-clean-act-boiler-room-tactics.html">exposure</a> of the “boiler room” tactics of the big charities including Oxfam, Cancer Research and Save the Children, who were accused of cold calling people who had signed up to a “no call” list on the UK telephone preference services, pressuring people to donate and asking for donations from vulnerable people who had dementia.</p>
<p>With <a href="http://dera.ioe.ac.uk/7133/">government policy</a> to expand public funding to the third sector and the decentralisation of commissioning in health there is <a href="http://www.birmingham.ac.uk/generic/tsrc/documents/tsrc/working-papers/working-paper-20.pdf">likely to be a growth</a> in <a href="http://www.nao.org.uk/wp-content/uploads/2005/06/050675es.pdf">sub-contracting services</a> to this sector. As a result we must be able to map which third sector organisations are working in health and social care and make distinctions about organisations on the basis of their capacity to provide quality care.</p>
<h2>The third sector</h2>
<p>Around <a href="http://data.ncvo.org.uk">800,000 people</a> work in the third or “voluntary” sector in the UK, and with more than 164,000 registered charities and a <a href="https://www.gov.uk/government/publications/charity-register-statistics/recent-charity-register-statistics-charity-commission">combined annual income</a> estimated at £64 billion, their role in providing social goods is not marginal.</p>
<p>The state funded the third sector to the tune of £13.9 billion in 2010, <a href="http://data.ncvo.org.uk/a/almanac12/what-are-the-main-trends-in-statutory-funding/">nearly half of which</a> came from local authorities. An estimated 437,000 third sector workers <a href="http://data.ncvo.org.uk/a/almanac12/what-is-the-voluntary-sectors-involvement-in-public-service-delivery/">are employed in health and social care</a> with 115,000 in residential care. </p>
<p>Much of the work with the most disadvantaged is carried out by religious groups, for example churches have historically <a href="http://www.pecan.org.uk">provided services for prisoners</a> and <a href="http://www.salvationarmy.org.uk/homelessness">the homeless</a>, social care <a href="https://humanism.org.uk/wp-content/uploads/BHA-Public-Services-Report-Quality-and-Equality.pdf">and education</a>, with a growing role in managing food banks <a href="http://policy-practice.oxfam.org.uk/publications/walking-the-breadline-the-scandal-of-food-poverty-in-21st-century-britain-292978">used by half a million people</a> in the UK. We are also seeing the growth of religious organisations sub-contracted to provide public services, such as welfare services <a href="http://www.crossreach.org.uk">in Scotland</a> and <a href="http://www.caringhandsuk.org.uk/about/index.html">in Kent</a>. </p>
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<figcaption><span class="caption">Mhairi Black’s maiden SNP speech: ‘food banks are not part of the welfare state, but a symbol of it failing’</span></figcaption>
</figure>
<p>Despite a long history of providing care, many religious groups are fundamentally sectarian in nature raising questions about universality of access when it comes to sub-contracting services.</p>
<h2>Social exclusion and the ‘dis-established’</h2>
<p>Third sector organisations have a competitive advantage when it comes to providing services: they have access to the people that need the help the most. The poor and vulnerable people who are hardest to reach.</p>
<p>Many people living in the UK are “dis-established” either by choice or necessity, <a href="http://www.jrf.org.uk/publications/monitoring-poverty-and-social-exclusion-2013">living outside of the social systems</a> set up to protect them. Some, like people with addictions or long term mental health problems, have exhausted state support or are unable to follow the treatment available. From <a href="http://www.jrf.org.uk/sites/files/jrf/migrants-private-rental-sector-summary.pdf">illegal immigration</a> to those <a href="http://www.iea.org.uk/sites/default/files/publications/files/IEA%20Shadow%20Economy%20web%20rev%207.6.13.pdf">working in the grey economy</a>, outside of labour regulation and national insurance systems, many people are excluded from health and social care, unable to give a name and address to even register at a GP practice. We don’t know how many families live by necessity outside of the social contract but as “<a href="http://www.theguardian.com/society/patrick-butler-cuts-blog/2013/jun/03/homeless-pensioner-offered-tent-by-council">cashless</a>” welfare reforms take place and poverty <a href="http://www.jrf.org.uk/topic/child-poverty">goes above 13m</a> people we can anticipate the number is growing. </p>
<p>But one of the inherent conflicts for third sector organisations is how public funding influences the principles on which they were established. This is acutely the case for charities, who legally cannot take a political position on the economic and social policies that are increasing the demand for their work. It means that an organisation like Kidsco <a href="http://www.thetimes.co.uk/tto/life/article4494696.ece">has to walk a very thin line</a> between continuing to access government funding and taking a position on the link between austerity and child poverty. </p>
<p>The lack of core funding for charities means that their accounts, although not technically corrupt, are often squeezed <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/438017/Trust_and_Confidence_in_the_Charity_Commission_2015.pdf">to fit the reporting requirements of donors</a>. It means that core salaries are hidden under “project coordination” and numerically defined outputs exaggerated to satisfy demands for value for money. All the while the unsustainability of many services in a climate of economic crisis and austerity is denied. It means that charities are often silenced when under attack. </p>
<h2>Getting the house in order</h2>
<p>Much of civil society is led by charismatic people who have a deep and sometimes obsessive belief in their cause. One of the problems with this commitment is that it can generate bullying by default. Where leaders are forced to sustain themselves for decades working unchallenged, their organisations can easily undermine the principles on which they are based. Many are run on guilt and the <a href="http://www.ucpress.edu/book.php?isbn=9780520221451">pressure for people within the system</a> to sacrifice their health for the greater good. A demand for total devotion and self sacrifice that walks the thin line between being right and becoming righteous.</p>
<p>The growth of third sector organisations in providing health and social care raises questions about organisational cultures and accountability. It also raises questions of equality and <a href="http://www.ucpress.edu/book.php?isbn=9780520221451">employment practices</a> for the people working within them, when issues of conscience and belief are a requirement for the job.</p>
<p>Challenging leadership is always hard, particularly when they operate on the moral high ground but that’s precisely what we have to do if we are to defend quality care. To do this we have to see civil society as it is. It is this realism that allows us to make the necessary distinctions between corruption and saying something that society doesn’t want to hear. If civil society is to protect the most vulnerable it has to be just that, civil, with the rights and responsibilities this entails. </p>
<p><em>This column looks at the reality of our health and care systems from the perspective of those working to deliver services. Please send us your anonymous <a href="http://survivingwork.org/top-tips/top-tip-1-how-to-restore-your-humanity/">stories from the frontline</a>.</em></p><img src="https://counter.theconversation.com/content/44730/count.gif" alt="The Conversation" width="1" height="1" />
In a week of Greek tragedies it has also been hard to distinguish the gods from the monsters in civil society. Three recent important stories about charities question the accountability and management…Elizabeth Cotton, Senior Lecturer, Middlesex UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/304832014-08-20T05:22:11Z2014-08-20T05:22:11ZHigh street pharmacies within a 20-minute walk could deliver more services<figure><img src="https://images.theconversation.com/files/56544/original/t43gmx7b-1408027361.jpg?ixlib=rb-1.1.0&rect=1%2C70%2C1022%2C676&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Got a drinking problem?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/sludgeulper/5964629811/sizes/l/">Sludgegulper</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>As a nation we smoke too much, drink too much alcohol and don’t do enough exercise. The reasons why we continue to do this despite the health risks is complex, but what is clear is that people in deprived areas are more likely to die of cardiovascular disease, certain cancers and liver disease – conditions closely associated with unhealthy lifestyles. While it’s easy to say we should just cut down on unhealthy behaviours and live better, this is proving to be more easily said than done.</p>
<p>One of the factors we know influence a person’s health is their access of healthcare services. Unfortunately, studies have shown <a href="http://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4c-equality-equity-policy/inequalities-distribution">that this isn’t equitable across the country</a> and it’s yet another thing that the more deprived miss out on.</p>
<p>In the majority of cases, access to healthcare services such as GP surgeries or walk-in centres tend to be worst in the poorest areas, and best in the most affluent. This observation was first made by former GP Julian Tudor Hart, who said that: “the availability of good medical care tends to vary inversely with the need for it in the population served.”</p>
<p>One exception to this, however, are community pharmacies – the ones you find on every high street – run by big companies down to smaller, independent outfits. </p>
<p>In England alone there are about 12,000 of them, open to all without the need to make an appointment and many are open late nights and weekends.</p>
<p>Over the last few years, the role of the community pharmacist has rapidly expanded from supplying medication to more of an emphasis on delivering health services. Many community pharmacists can now help people to quit smoking, lose or manage weight, and screen you to see if you’ve been drinking too much, within GP-style consultation rooms in the pharmacy. </p>
<p>In research we published <a href="http://bmjopen.bmj.com/content/4/8/e005764.full">in the BMJ Open</a> we found that these community pharmacies could play an even bigger part in how healthcare is delivered – not just to those in deprived areas, but the rest of us too. </p>
<p>We analysed the postcodes for all community pharmacies in England and the co-ordinates of each postcode for the population. These were then matched to a deprivation index as well as to the type of area, so whether it was urban, town and fringe, hamlet or an isolated dwelling. We found that 89.2% of the population could get to a community pharmacy within 20 minutes’ walk. As you might expect, access was greatest in urban areas compared to town and fringe and rural settings. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/56546/original/3w4y5jn8-1408027685.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Not all posh.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/chrisinplymouth/8571786788/sizes/l/in/photolist-e4sDzo-cwYgdw-oqCtGY-cwNzds-UNLD-ntF8DA-9oySCX-5133v2-4VVA4x-kBdR-2kiWGi-iPpxuo-djxhCv-foxv2a-degBJG-8XVgFq-7cFEiv-AMdV8-5JhUZM-bECmUb-5DAabD-LuS7Z-hp55A-7u6DZ-2kohQY-dHh7QF-6yH1H9-7C4H7U-7WuTeK-axB5r6-cYeun5-2Lcghx-axBi7Z-nRF5ME-5fYBvY-nvKBxQ-nJzj3S-didkT4-bCnTpD-neemQA-fqUGFK-7ChdkS-nvHSLk-g6cKbS-fUJXm-nhB5EP-ngKVbP-ni4qYQ-o3p21w-nXKjFp-nVHN7j/">Chrisinplymouth</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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</figure>
<p>In contrast to Tudor Hart’s inverse care law, almost 100% of households in the poorest areas lived within a 20-minute of a pharmacy. So for community pharmacies, a positive care law exists – with access to healthcare greatest in areas of greatest need.</p>
<p>Given that more people die from cardiovascular disease, certain cancers and liver disease – often as a result of smoking, obesity or alcohol misuse in areas of high deprivation compared to more affluent areas – this could be a ready-made way of reaching these groups. </p>
<p>Developing services that target at-risk groups is challenging for a number of reasons, and one major factor is the lack of access. Community pharmacies, therefore, appear to be uniquely placed in our society to deliver healthcare services targeted to patients that need them the most. </p>
<p>In terms of planning for the future, this is very significant and should be used by those making healthcare policy – and more should be done to let people know what services already exist and to ask why can more not be made available?</p><img src="https://counter.theconversation.com/content/30483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Todd does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As a nation we smoke too much, drink too much alcohol and don’t do enough exercise. The reasons why we continue to do this despite the health risks is complex, but what is clear is that people in deprived…Adam Todd, Fellow of the Wolfson Research Institute for Health and Wellbeing, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/224572014-01-29T09:48:37Z2014-01-29T09:48:37ZMachines spell change rather than doom for white-collar work<figure><img src="https://images.theconversation.com/files/40025/original/6579sq4v-1390921178.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A morning staff meeting gets underway in 2034.</span> <span class="attribution"><span class="source">Grathio</span></span></figcaption></figure><p>If Google chairman <a href="http://www.bbc.co.uk/news/business-25872006">Eric Schmidt</a> is to be believed, the automation of jobs will be the “defining” problem of the next two to three decades. At a debate at Davos 2014, he warned that the constant development of new technology will put more and more middle class people out of work.</p>
<p>This is a challenging assertion that will hit home to any parent or educator seeking to support the next generation of workers.</p>
<p>Schmidt sees the rise of automation as nothing short of a second Industrial Revolution. He believes the way work is conducted will be radically different in the future as many human tasks are automated by algorithms and computer services.</p>
<p>I initially agree with this assessment. Over the past 30 years, we’ve seen a dramatic shift in workplace IT. Once, islands of computing systems ran basic operations and finance administration from dedicated server rooms. Then the evolution of the PC and the internet put a computer on everyone’s desk. Now mobile devices and tablets, fuelled by massive social networks and multi-media digital services, have exploded the volume of information about people, products, places and workspaces on a planetary scale.</p>
<h2>Superfast computing</h2>
<p>Technology has not just brought us masses of connections and exabytes of information. When we passed a certain threshold in the level of computing power for devices that could sit in the palm of your hand, many tasks that previously required a high level of education and skill became infinitely simpler to carry out. </p>
<p>Tasks that are still difficult in 2014 may not be such and obstacle in <a href="https://theconversation.com/machines-on-the-march-threaten-almost-half-of-modern-jobs-18485">30 years</a>. Jobs that currently require the human touch could well be done by machines in the future, particularly as natural language processing advances. The automated question and answer services that many websites offer as a customer care service may seem clunky now, but that won’t always be the case.</p>
<h2>Blinded by the novelty</h2>
<p>In order to work out whether technology will lead to the demise of the white-collar worker, we have to think about how connected and pervasive these systems will become in our everyday lives.</p>
<p>At the moment, it’s not easy to tell because we are currently somewhat blinded by the novelty of today’s IT functionality. We are still getting to grips with the ability to carry out complex tasks on our phones and the power of the search function on a webpage. This is just the initial face of some of the services that have made ordering products and services or delivering on-demand multi-media entertainment, books and digital content easier. It’s only the customer side of the IT revolution and it is only the start. </p>
<p>Banking services are now much more commonly automated than in the past, removing the need for service desk and customer liaison staff. Over in retail, self-service and computerised stock tracking, both online and in real life, are gradually replacing workers.</p>
<p>Now we are seeing shift in economies of scale of knowledge in areas such as searching, tracking, buying and selling that are shifting from traditional physical jobs to online virtual work automated by machine algorithm and responses.</p>
<p>This hasn’t had a significant impact on large numbers of jobs yet but the main point raised by Schmidt at Davos is that things start to get more serious when IT services are connected to everyday objects like cars, homes and everyday products.</p>
<p>We can expect, for example, to see rooms and buildings functioning without the need for human intervention and traffic systems becoming fully automated.</p>
<p>If home appliances such as fridges or entertainment systems can plan ahead and restock themselves automatically based on their owner’s preferences, then whole links in the current supply chain become redundant. And if a home can automatically arrange repair services for itself, fewer human jobs are needed. If an office can do it, even fewer people are needed on the ground and since we’ll all be <a href="http://www.forbes.com/sites/danschawbel/2014/01/21/work-life-integration-the-new-norm/">working from home anyway</a>, we may not even have to wait until full automation before we start seeing humans being replaced.</p>
<p>And as transport moves towards increased automation, the role of humans is again uncertain. If emergency responses can be sent out when an alert is received from a patient’s monitoring device, fewer people are needed to man the phones. Go a step further and virtual reality and location-aware services could provide advice for travellers in villages, towns and cities.</p>
<p>Connecting these together in a nested ecosystem of automation has the potential to change the way whole job markets, countries and industries buy, sell and trade business. Wealth creation will shift away from being the responsibility of the human to the job of the machine.</p>
<h2>Life in the old dogs yet</h2>
<p>Before we give up all hope though, it’s worth remembering that human workers survived the earlier industrial eras of steam, electricity, telegraph and globalised media. We continued to work because with every new level of automation, new jobs are created that replace those that are lost.</p>
<p>Schmidt’s call for a debate is a timely reminder that all these things also have the potential to create new levels of human value and better lifestyles for people. Technology replaces humans in many ways but new opportunities are created to exploit these technologies too. A new era of work is upon us and new types of work will emerge to exploit the new technologies that we will use.</p><img src="https://counter.theconversation.com/content/22457/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Skilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If Google chairman Eric Schmidt is to be believed, the automation of jobs will be the “defining” problem of the next two to three decades. At a debate at Davos 2014, he warned that the constant development…Mark Skilton, Professor of Practice, Warwick Business School, University of WarwickLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/135632014-01-06T19:29:48Z2014-01-06T19:29:48ZPrivate health insurance rebates restrict consumer choice<figure><img src="https://images.theconversation.com/files/38505/original/55kz973g-1388982912.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some registered professions are being excluded from rebates for services they can provide.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The <a href="http://www.abc.net.au/news/2013-12-23/nib-to-lift-health-insurance-premiums-by-nine-per-cent/5172326">pre-Christmas announcement</a> that private health insurance premiums will rise by an average of 6.2% in 2014 has raised concerns about <a href="http://www.smh.com.au/federal-politics/political-news/health-minister-peter-dutton-approves-rise-in-private-insurance-premiums-by-more-than-previous-increase-20131223-2ztvv.html">affordability</a>. But while consumers aren’t expected to drop their cover because of the price rise, it ought to prompt closer scrutiny of the services insurers pay for.</p>
<p>Indeed, a recent <a href="http://www.accc.gov.au/">Australian Competition & Consumer Commission</a> (ACCC) <a href="http://transition.accc.gov.au/content/index.phtml/itemId/881749">inquiry</a> concluded the practice of providing rebates for some health professionals but not others – for the same or similar services – had serious consequences for both consumer choice and health professions.</p>
<h2>Scope of practice and legitimacy</h2>
<p>All regulated health professionals work within a “scope of practice”, which specifies the procedures and actions that they can competently undertake. The ACCC investigation found great variation between private heath insurers in providing rebates for services within allied health occupations’ “scope of practice”. </p>
<p>Orthopaedic surgeons, for instance, are more likely than podiatric surgeons to be rebated for foot and ankle surgery; nutritionists are more likely than dietitians to get recognised for nutrition services; psychotherapists, counsellors and psychologists are more likely than clinical hypnotherapists to be rebated for hypnotherapy; and physiotherapists are more likely to be funded for hand splints and orthoses than occupational therapists. </p>
<p>There’s overlap between the procedures of different professions, but the ACCC report shows that some registered professions are being excluded from rebates for services they can provide; while other professions performing similar services are recognised. </p>
<p>Getting private health rebates for services is a particularly important signifier of the value of health professions. The rebate indicates to the public that such a provider and their service is legitimate. </p>
<p>While it’s arguable that as long as a service is covered, it doesn’t matter who provides it, that fails to acknowledge that legitimacy in the form of rebates is critical to the growth of the diversity of occupations we need to <a href="https://theconversation.com/hike-in-health-costs-should-prompt-workforce-rethink-9790">tackle future health issues</a>, such as chronic illness.</p>
<p>It also doesn’t acknowledge that <a href="http://informahealthcare.com/doi/abs/10.3109/09638288.2012.720346">not all Australians</a>, particularly those in living in rural and remote areas, have a choice about who provides the services they need.</p>
<h2>Lack of evidence</h2>
<p>Insurer preferences entrench views about particular occupations in health that may not be based on research evidence. Such perceptions of legitimacy can have a cascading effect. </p>
<p>Even when there are rebated services for evidence-based interventions, <a href="http://onlinelibrary.wiley.com/doi/10.1111/1440-1630.12030/abstract">our research</a> on chronic diseases found doctors are less likely to refer to occupational therapists than physiotherapists, indicating that even health professionals may not be aware of the scope of practice of various allied health professions. </p>
<p>Health care is a competitive market. The ACCC noted that “the non-recognition of a category of allied health-care provider can affect the employment prospects and income of those providers”. This raises the question of how decisions about which providers to rebate are made. </p>
<p>Insurers claim that there are “common elements” of their decisions, which are:</p>
<ul>
<li>clinical efficacy of the service offered by the provider</li>
<li>legal requirements relating to accreditation and registration </li>
<li>the administrative costs to the insurer in recognising a provider and </li>
<li>issues relating to member demand and expected cost of claims. </li>
</ul>
<p>While consumer demand is important, according to the ACCC, “it can be difficult for consumers to identify the categories of allied health care provider recognised to provide a particular service covered under a PHI [private health insurance] product”.</p>
<h2>Great expectations</h2>
<p>Private health insurers seem to expect that consumers are aware of the scope of practice of the range of allied health professions. And, even more unrealistically, that consumers will know which therapies have an evidence base. </p>
<p>The selection of particular providers is not made transparent to consumers, and at the very least, calls for clearer communication about what providers and services are covered in health insurance policies.</p>
<p>Apart from reference to clinical efficacy of both services and providers as one of the factors taken into account, very little of the decisions appear to be based on evidence of benefit. Rebates for allied health services appear to be more of a commercial decision than linked to provision of best health care. </p>
<p>Similarly, the rebating of complementary and alternative health services by insurers indicates clinical efficacy <a href="https://theconversation.com/private-health-insurers-natural-therapy-rebates-in-the-spotlight-12706">may not be</a> the primary driver of which services are rebated. The process behind rebates is not communicated clearly to consumers who may erroneously assume that rebated services have been found to produce health benefits. </p>
<p>In Australia, one of the key consequences of such disparity in service relates to access. If people in rural and remote areas don’t have ready access to an approved service provider, they can seek the services of another practitioner, but they will pay more, even if they also pay for private health insurance cover. </p>
<p>Australians need more information about what professions and services are rebated in private health insurance. And they need to know how rebates come to be assigned.</p><img src="https://counter.theconversation.com/content/13563/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Willis receives funding from the Australian Research Council to investigate the topic of health care choice.</span></em></p><p class="fine-print"><em><span>null</span></em></p><p class="fine-print"><em><span>Michelle Lincoln receives funding from NHMRC, ARC and FACHSIA.</span></em></p>The pre-Christmas announcement that private health insurance premiums will rise by an average of 6.2% in 2014 has raised concerns about affordability. But while consumers aren’t expected to drop their…Karen Willis, Health sociologist, qualitative researcher, University of SydneyLynette Mackenzie, Associate Professor, Occupational Therapy, University of SydneyMichelle Lincoln, Professor of Speech Pathology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/161402013-07-23T04:59:34Z2013-07-23T04:59:34ZThe technology that remembers the past for those who can’t<figure><img src="https://images.theconversation.com/files/27645/original/bbmpxtkb-1374080416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Portrait helps keep the good times alive for dementia patients</span> <span class="attribution"><span class="source">leakytr8</span></span></figcaption></figure><p>Care homes in Scotland are taking on a new type of technology to help improve the service they give to residents, particularly those suffering from dementia.</p>
<p>With the help of digital portraits, staff can quickly access information about a patient’s backstory in order to better understand their needs and engage them in conversation, even when they are pressed for time.</p>
<p>The increasing demands placed on careworkers make it difficult for them to establish meaningful connections with residents. Balancing heavy case loads with the actual job of caring, high staff turnover and part time working patterns all serve to exacerbate the problem.</p>
<p>Dementia costs the UK £17 billion per year and with an ageing population, our care homes are fuller than ever before. At the same time, memory loss and communication problems make caring for residents with dementia particularly challenging. </p>
<p>But Dundee-based researchers Dr Gemma Webster and Professor Vicki Hanson have developed software to address this problem as part of the Social Inclusion through the Digital Economy research hub.</p>
<p><a href="http://www.side.ac.uk/accessibility/case_study/portrait">Portrait</a> has already been installed in Balhousie care homes in Scotland and plans are underway to expand its use elsewhere.</p>
<p>The system consists of multimedia portraits of each resident presented on an easy-to-use touch screen. The portrait can be clicked on to reveal information about key events in the patient’s life, their family and hobbies. There is a photo of what the resident looks like now as well as pictures from their past. Staff can access information about holidays, weddings and even the patient’s childhood. They can then use this information to stimulate discussions with the person about their life and interests. </p>
<p>By reading short anecdotes about the scrapes a patient got into as a child, for example, the carer has something light to talk about before they have even approached the resident. In short, Portrait helps carers know who the patient is and, crucially, who they were before they came to the care home.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=234&fit=crop&dpr=1 600w, https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=234&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=234&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=294&fit=crop&dpr=1 754w, https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=294&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/27646/original/6yggznhr-1374080718.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=294&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">What’s your story?</span>
</figcaption>
</figure>
<p>There is also information about the resident’s current likes and dislikes, such as whether they prefer to sit in the kitchen or the living room, if they don’t eat a particular food or if they are resistant to certain routines. In this way, personal information can also be used to inform the way in which the carer actually provides their services to the resident.</p>
<p>This is the first time a technology like this has been developed with the care provider in mind. To date, much research and several commercial offerings have aimed at memory books and reminiscence therapy for people with dementia. Portrait is unique because it specifically targets the work schedules and usability needs of care staff. It helps a busy caregiver, who often hasn’t had the opportunity to get to know a resident, see the whole person, rather than just the illness. They are encouraged to treat the person as an individual rather than as just a set of needs to service.</p>
<p>It is designed so that care staff can use the system alone in a setting such as a work room and find interesting information about a person in just three minutes. This is particularly important for residents with communication difficulties, such as those that arise from late stage Alzheimer’s and other forms of dementia. It often takes time and skill to engage these residents in a way that can help them feel more at ease so technology that takes some of the burden away can make a real difference.</p>
<p>Nothing can replace developing long-term relationships with the people in care homes but circumstances are conspiring more and more to make this difficult. Technology like Portrait will be needed now and in the future to help residents feel less isolated and more cared for.</p><img src="https://counter.theconversation.com/content/16140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Watson receives funding from Research Councils UK through its Digital Economy theme.</span></em></p>Care homes in Scotland are taking on a new type of technology to help improve the service they give to residents, particularly those suffering from dementia. With the help of digital portraits, staff can…Paul Watson, Professor of Computing Science, Newcastle UniversityLicensed as Creative Commons – attribution, no derivatives.