tag:theconversation.com,2011:/uk/topics/aande-22540/articlesA&E – The Conversation2023-12-20T10:19:44Ztag:theconversation.com,2011:article/2198372023-12-20T10:19:44Z2023-12-20T10:19:44ZAlcohol, artificial trees and ‘granny dumping’: why Christmas is such a busy time in A&E<figure><img src="https://images.theconversation.com/files/566253/original/file-20231218-25-c3sqs8.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5447%2C3637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Christmas day is actually the least busy day in A&E during the holidays.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blur-image-patients-hospital-waiting-see-1142067620">Medical-R/ Shutterstock</a></span></figcaption></figure><p>Christmas is a time for families and friends to come together, relax and enjoy themselves. It’s a time of giving and receiving and of feasting – and perhaps, for some, a celebratory tipple. But sometimes, yuletide plans can go awry. And some of these purported pleasures might lead to a visit to the local emergency department.</p>
<p>The holiday season is often one of the busiest times in A&E departments in the UK and <a href="https://emj.bmj.com/content/28/5/373">around the world</a>. But Christmas day itself is actually the least busy day of the bunch. In my A&E department, attendances temporarily fall by up to a third on Christmas day.</p>
<p>This is perhaps unsurprising, as people will want to be with their families on December 25th. So those who might have otherwise visited the emergency department with <a href="https://www.lep.co.uk/health/seven-figure-cost-of-unnecessary-ae-visits-in-preston-and-chorley-3138023">less urgent reasons</a> for attending may prioritise their family time on that day instead.</p>
<p>Unfortunately, the remainder of the Christmas season sees a surge in attendances – *<em>and the number of these Christmas attendances in the UK is rising by <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2023/01/Statistical-commentary-December-2022-cftre1.pdf">around 4% each year</a>.</em> </p>
<p>The reasons for this surge are quite complex. One explanation is that primary care is less available over the holidays. We actually see the same sort of surge in A&E attendances <a href="https://www.dailyecho.co.uk/news/17615949.doctors-call-better-medical-awareness-easter-surge/">around Easter</a> too.</p>
<p>Another reason is that patients are unable to visit their general practitioners, so they go elsewhere, often <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/hex.12995">to the emergency department</a>.</p>
<p>This time of year is particularly stressful for staff, so many apply for <a href="https://www.myemergencydr.co.uk/media-centre/staffing-crises-in-emergency-departments-this-christmas-its-different">annual leave over that time</a> as a consequence. Senior staff are also <a href="https://www.sthelensstar.co.uk/news/23797617.hospitals-face-christmas-day-staffing-due-strikes/">often unavailable</a> because staffing is reduced and many want to be with their families.</p>
<p>All of these factors combined explain why A&E is often uniquely packed around the holidays. Some of the problems that land people in A&E at this time of year are also unique to the Christmas period. </p>
<h2>Overindulgence</h2>
<p>Food, alcohol and drugs are often taken to excess at Christmas. </p>
<p>Alcohol is a <a href="https://www.sciencedirect.com/science/article/pii/S0165032716323035">common reason for attendances</a> during public holidays worldwide. <strong>Even on regular weekends, <a href="https://emj.bmj.com/content/33/3/187?ijkey=985e35e0f484d37e5dfea06970d0d99a46a58b05&keytype2=tf_ipsecsha">up to 70% of A&E attendances</a> in the UK are alcohol related.</strong> </p>
<p>Alcohol intoxication is a <a href="https://academic.oup.com/alcalc/article/54/5/516/5524731">significant burden</a> on emergency departments. Unruly drunken patients may cause disruption. Patients who are rendered unconscious by alcohol require careful monitoring to ensure they don’t fill their airways with vomit.</p>
<p>Gluttony can also bring someone to the emergency department. Eating and drinking too much can cause acid reflux, which in severe cases can mimic the <a href="https://health.ucdavis.edu/news/features/telling-the-difference-between-heartburn-and-heart-attack/2022/12#:%7E:text=Indigestion%20can%20cause%20acid%20reflux,but%20not%20to%20the%20extremities.">symptoms of a heart attack</a>. However, the number of these attendances are dwarfed by the number of those related to alcohol misuse.</p>
<h2>Accidents</h2>
<p>Christmas presents can sometimes be a significant threat to safety.</p>
<p>Over 40 years ago, <a href="https://www.sciencealert.com/chemistry-kits-history-risks-benefits-education">poisoning and burns related to chemistry sets</a> were quite common and sometimes fatal. In more recent times, it’s <a href="https://www.tandfonline.com/doi/abs/10.1080/07420528.2021.1993239">electric scooters</a> which have become a significant threat due to collisions and lithium battery-related fires. </p>
<p>Christmas trees – particularly artificial ones – can also <a href="https://www.newyorker.com/tech/annals-of-technology/christmas-decoration-injuries">cause injuries</a>. In fact, <a href="https://www.sciencedirect.com/science/article/abs/pii/S2212958818301769">artificial Christmas trees</a> carry a sixfold higher risk of injury over real ones. Fires, electrical injuries and blunt injuries have all been reported. </p>
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<img alt="A father and daughter wearing santa hats put up their artificial Christmas tree." src="https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=353&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=353&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=353&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=444&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=444&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566254/original/file-20231218-17-acgmnu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=444&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">Danger may be lurking in your Christmas tree.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/father-daughter-install-artificial-christmas-tree-2199216143">Andrew Angelov/ Shutterstock</a></span>
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<p>Some of those glass baubles can be quite nasty too. The glass is sharp, thin and in my experience, sometimes quite difficult to locate and extract from a wound.</p>
<h2>Violence</h2>
<p>Christmas is said to be the season of good will. Sadly, this is not always the case. The Christmas period sees an <a href="https://link.springer.com/article/10.1007/s10140-022-02103-8">increase in the incidence of assaults</a>. These are commonly alcohol related, and may occur within families or even outside in the community.</p>
<p>There’s also an increase in <a href="https://metro.co.uk/2022/12/20/one-in-four-women-are-worried-about-sexual-assault-over-christmas-17968012/">sexual assault</a> and <a href="https://www.dvact.org/post/why-does-domestic-violence-increase-over-christmas">domestic violence</a> at Christmas. Much of this comes to the emergency department. </p>
<h2>Poor mental health</h2>
<p>Loneliness is rife in old and young alike. Christmas sees an increase in those feeling desperate – and in some cases, <a href="https://www.mind.org.uk/news-campaigns/news/mind-warns-that-people-with-mental-health-problems-struggle-with-self-harm-and-suicidal-feelings-due-to-the-pressure-of-christmas/">harming themselves</a>.</p>
<p>Psychiatric services come under <a href="https://mentalhealth-uk.org/blog/what-its-like-to-work-in-mental-health-support-over-christmas/">particular pressure at this time</a>. The number of these attendances at Christmas are no higher compared to <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2022.1049935/full">the rest of the year</a> but services are less well staffed so patients may be waiting longer for support. </p>
<h2>Elder abuse</h2>
<p>One of the most egregious things we see in emergency departments is the abandonment of elderly relatives by families wishing to rid themselves of them for a quieter time at home or perhaps make their holiday celebrations easier.<strong>Known as “<a href="https://www.cbc.ca/news/canada/london/elderly-relatives-granny-dumping-holidays-1.6295864">granny dumping</a>, this involves people bringing a relative to A&E in the days before Christmas, claiming they require care and need to be admitted to hospital for monitoring.</strong> Figures on this are hard to come by, but it’s <a href="https://www.bigissue.com/news/politics/adam-kay-its-christmas-everyday-in-the-nhs-but-not-in-a-good-way/">seen widely</a> in <a href="https://www.irishexaminer.com/opinion/commentanalysis/arid-40195434.html#:%7E:text=One%20is%20the%20use%20of,decline%20to%20bring%20them%20home.">emergency departments</a>.</p>
<p>Emergency departments continue to function over the festive season. Patients present with all manner of emergencies that require immediate treatment, and by no means are they all due to human folly. In fact, such presentations are a minority.</p><img src="https://counter.theconversation.com/content/219837/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Hughes 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>Some of the reasons people end up in A&E at Christmas are unique to the season.Stephen Hughes, Senior Lecturer in Medicine, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1729012021-12-10T13:43:44Z2021-12-10T13:43:44ZA&E wait times: why the four hour target might need a re-think<figure><img src="https://images.theconversation.com/files/436905/original/file-20211210-137612-ucm75e.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5463%2C3645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are some misconceptions about what the four hour target actually means.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blur-image-patients-hospital-waiting-see-1142067620">Medical-R/ Shutterstock</a></span></figcaption></figure><p>People who attend accident and emergency (A&E) departments in the UK are supposed to be admitted, transferred or discharged <a href="https://www.nuffieldtrust.org.uk/resource/a-e-waiting-times#background">within four hours</a>. But these targets haven’t been hit in England <a href="https://www.bbc.co.uk/news/health-47485592">since 2015</a>. In October of this year, A&E departments in England only achieved the four hour standard for <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2021/11/Statistical-commentary-AE-October-2021.pdf">74% of patients</a>. In Wales, the situation was even worse, with the four hour target only being achieved for around <a href="https://statswales.gov.wales/v/Ktts">65% of patients</a>.</p>
<p>There are many reasons why this is the case – including increased demand due to an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564089/">ageing population</a>, struggling primary and community care services causing people to rely on A&E when it <a href="https://bmjopen.bmj.com/content/7/4/e013816">might not be clinically necessary</a>, and lower capacity due to <a href="https://www.nuffieldtrust.org.uk/news-item/a-e-departments-are-experiencing-a-perfect-storm-of-factors-leading-to-an-increase-in-waiting-times">under-staffing and inadequate bed space</a> for patients. The pandemic has only further increased pressure on A&E departments.</p>
<p>The four hour A&E target was first introduced <a href="https://webarchive.nationalarchives.gov.uk/ukgwa/20130123203805/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002960">in 2004</a> with the aim of reducing waiting times and helping to <a href="https://www.patientsforumlas.net/uploads/6/6/0/6/6606397/making_the_case_for_the_four_hour___standard_copy.pdf">combat overcrowding</a>. However, the creation of the target itself wasn’t based on <a href="https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_position_statement_Improving_quality_indicators_and_system_metrics.pdf">evidence or expert opinion</a>.</p>
<p>There are some misconceptions about the target – for instance, some may believe that it means a person should wait no more than four hours before being seen by a clinician. What the target actually means is that within four hours of arrival at A&E, a patient should be seen, treated and discharged, or admitted to a ward. This time might include multiple interactions with clinicians, waits for diagnostic tests and doctors or nurses checking in with other areas of the hospital. </p>
<p>There are a many reasons why the target might be missed – such as if a patient needs <a href="https://doi.org/10.1186/s12873-017-0145-2">more investigation</a> for a certain condition, or because of overstretched services outside of the emergency department. Other delays might be due to a <a href="https://webarchive.nationalarchives.gov.uk/ukgwa/20130105030902/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122868">lack of community support</a>, especially if a patient needs ongoing care after they leave, which <a href="https://doi.org/10.1186/s12873-017-0145-2">might not be available</a>. For example, an elderly patient who attends A&E due to a fall might need a home safety assessment or a care plan in place to ensure it’s safe for them to go home. While this is an issue outside the remit of the emergency department, it could still be reflected in the four hour target.</p>
<h2>Pros vs cons</h2>
<p>For many years, there’s been discussion of the target’s relevance and whether or not it should be scrapped. </p>
<p>Proponents of the four hour target argue that it’s <a href="https://doi.org/10.1136/emermed-2014-204479">associated with fewer deaths</a> and that it might be used to <a href="https://doi.org/10.1136/bmj.j4857">improve staffing levels</a> – by arguing that if a department is missing its target, it needs more resources. </p>
<p>But critics of the target point out there’s <a href="https://doi.org/10.1136/bmj.j4857">no evidence-based reason</a> why four hours is the specified time. They also emphasise that it tells us <a href="https://webarchive.nationalarchives.gov.uk/ukgwa/20130105030902/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122868">very little</a> about the patient’s care – for instance, why they didn’t receive care during the four hours.</p>
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<img alt="A doctor and nurse are tending to a patient." src="https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436906/original/file-20211210-19-mylv8t.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">There are both positives and negatives to the four hour target.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/couple-hispanic-doctors-looking-patient-vitals-533672494">antoniodiaz/ Shutterstock</a></span>
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<p>The targets have also been linked to <a href="https://emj.bmj.com/content/29/12/e2">staff stress</a> and a shift in focus from quality of care to <a href="https://emj.bmj.com/content/emermed/24/6/402.full.pdf">timeliness</a>. In other words, meeting the target might pressure staff into making decisions that prioritise meeting the target, as opposed to what’s best for the patient. Research also suggests the four hour target has not resulted in <a href="https://doi.org/10.1111/j.1742-6723.2010.01330.x">consistent improvements</a> in patient care – with high variability between hospitals. Improvements aren’t always clearly linked to the target itself either.</p>
<p>Ultimately, the Royal College of Emergency Medicine acknowledges these drawbacks, but recommends keeping the target as they believe it incentivises <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2010.01330.x?saml_referrer">timely care for patients</a>. But many patients <a href="https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20190311%20Submission%20to%20NHSE%20Clinical%20Standards%20Review%20-%20AE%20-%20final.%20docx_0.pdf">don’t mind waiting</a>, as long as they’re triaged promptly and told how long they might have to wait for treatment – and why.</p>
<h2>The future of A&E</h2>
<p>Given many A&E departments still fall short despite the four hour target, there’s a clear need for better measures. But instead of focusing on overall length of stay, future measures might shine a light on the stages at which patients are experiencing delays. There are some signs that this is happening, but such new measures will only work if the data collected from them is actually used to continue making improvements to benefit patients.</p>
<p>In December 2020, NHS England published plans to transform the way <a href="https://www.england.nhs.uk/wp-content/uploads/2020/12/transformation-of-urgent-and-emergency-care-models-of-care-and-measurement.pdf">A&E performance is measured</a>. The recommendations include measuring the percentage of ambulance handovers within 15 minutes, the time to initial assessment, and the average time spent in the department.</p>
<p>In Wales, three new measures were introduced <a href="https://nccu.nhs.wales/urgent-and-emergency-care/framework/">in 2020</a> which are <a href="https://nccu.nhs.wales/urgent-and-emergency-care/experimental-kpis/">reported upon monthly</a>. These include how long a patient waits to be triaged, how long until they see a decision-making clinician, and what the outcome was – such as if they were referred to a GP or outpatient service.</p>
<p>These measures were developed through collaboration with people working in emergency departments in Wales and are underpinned by <a href="https://rcem.ac.uk/wp-content/uploads/2021/10/SDDC_Intial_Assessment_Feb2017.pdf">clinical guidelines</a>, which recommend patients are seen within 15 minutes of arrival to ensure high risk patients are identified early so they can receive critical treatments. It’s also recommended that patients are seen by a clinician as early as possible after triage. It’s hoped these measures will help drive improvement. </p>
<p>The pandemic has had an undeniable impact on emergency care. But it has also highlighted the pressures emergency departments were <a href="https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Position_statement_Resetting_Emergency_Care_20200506-3.pdf">already under</a> and asked us to reconsider how to ensure patients are receiving the best care possible. The plans recently introduced in England and Wales, which emphasise stages of emergency care over a single time target, may be a step in the right direction.</p><img src="https://counter.theconversation.com/content/172901/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katie Jones holds an honorary contract with The National Collaborative Commissioning Unit, hosted by Cwm Taf University Health Board. </span></em></p><p class="fine-print"><em><span><a href="mailto:j.y.rance@swansea.ac.uk">j.y.rance@swansea.ac.uk</a> receives funding from the National Collaborative Commissioning Unit, hosted by Cwm Taf University Health Board.</span></em></p>Given many departments fall short of the target, it’s time to re-think how A&E departments deliver care.Katie Jones, Postdoctoral Researcher, College of Human and Health Sciences, Swansea UniversityJaynie Rance, Professor of Health Psychology, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1061942018-11-02T11:25:23Z2018-11-02T11:25:23ZChildren account for almost half of all visits to A&E for sports injuries<figure><img src="https://images.theconversation.com/files/243499/original/file-20181101-83661-y2wrsf.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/download/confirm/648458734?src=f654tBJfLyDx8CUcen5DfA-1-10&size=medium_jpg">Papuchalka/Shutterstock</a></span></figcaption></figure><p>Encouraging children to play sport is a key part of the <a href="https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action">UK government’s childhood obesity strategy</a>. The argument goes that children who play sport are physically active and therefore less likely to be obese. The problem with this argument is that the proponents conflate the undoubted benefits of physical activity, for which there is a great deal of evidence, with playing sport, for which there is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4444042/">no clear evidence</a> that it helps reduce obesity. </p>
<p>While the benefits of sport are often overemphasised, the risk of injury is <a href="https://www.allysonpollock.com/wp-content/uploads/2016/04/BJSM_2016_Pollock_RemovingContactFromRugby-2.pdf">usually ignored</a>. Yet <a href="https://www.ncbi.nlm.nih.gov/pubmed/26701986">studies</a> from <a href="https://www.ncbi.nlm.nih.gov/pubmed/15466146">the US</a> show that sports injuries are a major reason for children attending emergency departments and that sports injuries account for <a href="https://www.ncbi.nlm.nih.gov/pubmed/23603654">one-third of life-threatening injuries</a>. Attendances resulting from concussion due to sports injuries have tripled over eight years. </p>
<p>For decades, the UK government has failed to collect injury data in a systematic way – and so most of the data on sport comes from ad hoc surveys, which are often dismissed by critics as incomplete. The government has now partly remedied this deficit by introducing the NHS Emergency Care Data Set (ECDS), which will collect data from all hospitals in England. The ECDS has the potential to provide data on all sports-related injuries needing emergency treatment in England.</p>
<p>In 2012, we were invited to <a href="https://jech.bmj.com/content/early/2016/10/08/jech-2016-207581.info">analyse injury data</a> from the pilot site of two NHS hospitals that were testing the feasibility of collecting injury data: the John Radcliffe in Oxford and Horton General Hospital in Banbury. We analysed all data collected on people attending the emergency departments for injuries between January 1, 2012 and March 30, 2014 and all hospital admissions for injuries.</p>
<h2>Worrying results</h2>
<p>Our analysis of the data <a href="http://journals.sagepub.com/doi/full/10.1177/0141076818808430">revealed that</a> of the nearly 64,000 people attending the emergency departments with an injury during this period, sports injuries accounted for almost one in five attendances, across all ages. Children and young adults (up to 19 years of age) accounted for almost half of all sports-injury emergency attendances and one-quarter of all inpatient admissions for serious trauma related to sport. Fourteen-year-old boys and 12-year-old girls were most at risk of sustaining a sports injury. These figures are similar to those in the US and Australia.</p>
<p>For boys, five sports accounted for two-thirds of sports injuries, the top three being football, rugby union and rugby league. For girls, five sports accounted for almost half of all injuries, the top three being trampolining (in the younger age groups), then netball and horse riding. </p>
<p>Almost one-quarter of all attendances for sports injuries were due to fractures, the highest proportion being for broken arms and collar bones. Rugby union was the sport most associated with head injury and concussion in boys. For girls, head injuries were most common during horse riding. Collision sports such as rugby and rugby league, which are played far less frequently than football and other non-collision sports, dominate A&E attendances for sports injuries. </p>
<p>All schools have a duty to keep children from harm. Sports England safeguarding strategy has largely focused on sexual abuse, but it should focus as much attention on the physical and mental risks of abuse and harms from sports injury, and it should work with schools and clubs to target sports-injury prevention at children in the first four years of secondary school. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/243503/original/file-20181101-83635-1i5mlkp.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">Fun, but potentially harmful.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/795553993?src=zkgwCLYEWonjEMYx8tj2mg-1-69&size=medium_jpg">Martin Novak/Shutterstock</a></span>
</figcaption>
</figure>
<p>For younger age groups, trampolines in the home need to be made safer. For older boys, schools should investigate mechanisms and causes of injury for football, and ban tackling in rugby as this is the phase of play <a href="https://bjsm.bmj.com/content/early/2017/07/06/bjsports-2016-096996.info">when most injuries occur</a>. For girls, we need to investigate ways to make netball, horse riding and trampolining safer.</p>
<p>If we extrapolate our figures to the whole of England, it’s equivalent to 68 boys and 34 girls in every thousand attending NHS emergency departments in a year due to sports-related injury. This is a heavy burden on the NHS and on children and families and carers and schools. An injured child is an inactive child – and time lost from school and harm to mental well-being as a result of injury also need to be considered. Children need to be physically active, but making organised sports as safe as possible must be part of any effective child obesity strategy.</p><img src="https://counter.theconversation.com/content/106194/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>A first look at data on sport injuries in children in England, and it’s not a pretty picture.Allyson M Pollock, Professor of Public Health, Newcastle UniversityGraham Kirkwood, Senior Research Associate, Newcastle UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/938232018-04-10T13:04:19Z2018-04-10T13:04:19ZSore throats and false nails – the ambulance call-outs that cost millions<figure><img src="https://images.theconversation.com/files/213378/original/file-20180405-189816-16eq9co.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/download/confirm/635231459?src=LmNvxGpySO2Qgc38lOyJ4w-1-10&size=medium_jpg">Brian A Jackson/Shutterstock</a></span></figcaption></figure><p>Ambulance call-outs are increasing, resulting in services operating under enormous, and probably <a href="https://www.nao.org.uk/wp-content/uploads/2017/01/NHS-Ambulance-Services.pdf">unsustainable</a>, pressure. While most calls do need an emergency response, far too many don’t. A <a href="http://emj.bmj.com/content/15/6/368?ijkey=35f7564aa3963e4790e1e42e9f87404453ff9736&keytype2=tf_ipsecsha">study</a> of 300 consecutive emergency ambulance arrivals to an accident and emergency (A&E) department in London, England, found that only 54% of the patients legitimately needed an ambulance.</p>
<p>The tabloid press are fond of reporting daft ambulance call-outs, like one to revive a <a href="http://metro.co.uk/2017/12/30/these-are-some-of-the-most-ridiculous-calls-made-to-999-7110082/">dead pigeon</a>, and another to see if McDonald’s had run out of <a href="https://www.express.co.uk/entertainment/books/379058/999-numpties-The-daftest-calls-the-emergency-services-have-ever-had-revealed-in-new-book">chicken nuggets</a>. Funny though they are, these kinds of calls <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-11-258">put a strain on services</a> and take paramedics away from emergencies that are genuinely life threatening. </p>
<p>These calls can also be truly disheartening for paramedics who see themselves as health professionals who are there to treat people and save lives. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4817967/pdf/policy-11-067.pdf">Research</a> has found this to be a common concern among paramedics who are obliged to respond to patients no matter how silly they perceive the call to be. In my ongoing study of the perceptions of patient safety in three English ambulance service NHS trusts, a call-taker in the emergency operations centre told me of their frustration:</p>
<blockquote>
<p>I have questioned one drunken man’s request for an ambulance because he had a sore throat, and this is when there were 23 calls waiting to get through, and I was angry about that.</p>
</blockquote>
<p>Their anger at situations like these is both understandable and common, with one paramedic involved in my study discussing his concern for other patients with legitimate emergencies, when having to respond to calls they find to be ridiculous:</p>
<blockquote>
<p>You laugh, but when I started I got a call-out to a girl because of false nails. She’d been playing with her boyfriend, bent her nail, bent back and the nail come off … And while I’m dealing with that, there could be a cardiac arrest somewhere, someone could be stuck under a lorry.</p>
</blockquote>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213395/original/file-20180405-189795-1cgr28n.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">Not an emergency.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/266479175?src=ts4zLx2NNbItcdkoVXeZNQ-1-39&size=medium_jpg">CRM/Shutterstock.com</a></span>
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</figure>
<p>As well as tying up resources that could be used to treat genuine medical emergencies and increasing the waiting times at A&E departments, these calls can be expensive for the ambulance services. In the UK, <a href="https://www.gov.uk/government/publications/nhs-reference-costs-2014-to-2015">each call costs</a> about £7, £180 if an ambulance is sent to treat a patient and £233 if the patient is brought to the emergency department. Given that a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4817967/pdf/policy-11-067.pdf">significant portion</a> of calls are seen as not requiring an emergency response, this can add up to millions of pounds every year. </p>
<h2>24/7 culture</h2>
<p>Although the rise in the rate of demand for ambulance services, at <a href="https://www.sheffield.ac.uk/polopoly_fs/1.366348!/file/Evidence_on_Access_and_Behaviour.pdf">6.5% each year</a>, is relatively recent in the UK, inappropriate call-outs have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1343207/pdf/jaccidem00027-0002.pdf">documented</a> in research going back at least two decades. <a href="http://emj.bmj.com/content/emermed/31/6/448.full.pdf">One study</a> proposed a couple of reasons why patients phone the emergency services for conditions that could be treated in primary care, including difficulty getting a GP appointment and a perception that they will be treated more quickly. </p>
<p>The high number of inappropriate calls could also be attributed to a <a href="https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2015/jan/12/a-and-e-patients-dont-need-ambulance">24/7 culture</a>, where people expect immediate treatment for any condition, no matter the severity. A paramedic in my study considered it to be a generational problem, with millennials making the most of these calls:</p>
<blockquote>
<p>It’s a great generation, but young people today don’t understand what the services are for, and we didn’t have this problem as bad some decades ago. They will call us for just about anything.</p>
</blockquote>
<h2>Public awareness</h2>
<p>With <a href="https://www.nao.org.uk/wp-content/uploads/2017/01/NHS-Ambulance-Services.pdf">demand</a> projected to increase in coming years, it is clear that the ambulance services need to address the issue of inappropriate call-outs soon. Many things can be done to lessen the pressures of demand and to allocate the resources of the ambulance services more efficiently. However, to reduce the number of silly call-outs, it’s clear that public perception of what the ambulance service is for, needs to change. </p>
<p>Awareness could be spread through educational campaigns, using social media to reach the patients online, such as South Central Ambulance Service’s <a href="http://www.scas.nhs.uk/news/campaigns/misuse-costs-lives/">999 Misuse Costs Lives</a> campaign, which informed patients of when it’s appropriate to dial 999 and when it’s appropriate to use a different service, such as a GP clinic. </p>
<figure>
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</figure>
<p>Although changing people’s expectations is essential, a more holistic approach will also be necessary – one that gives patients appropriate access to alternative care settings, such as their GP or <a href="https://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/Walk-incentresSummary.aspx">walk-in centres</a>. Until this is done, some people will continue to rely on the ambulance service to treat minor ailments.</p><img src="https://counter.theconversation.com/content/93823/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keegan Clay Shepard 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>Overstretched ambulance services are increasingly being called out for non-emergencies.Keegan Clay Shepard, PhD Student and Graduate Teaching Assistant, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/913442018-02-06T16:00:46Z2018-02-06T16:00:46ZWho has to pay for the NHS and when?<figure><img src="https://images.theconversation.com/files/205055/original/file-20180206-14104-1muj2t5.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Care – with charges. </span> <span class="attribution"><span class="source">G.Ware</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>It will soon cost migrants from outside the EU £400 a year to access the National Health Service in Britain, after the government <a href="https://www.doctorsoftheworld.org.uk/Handlers/Download.ashx?IDMF=f6a9d7c2-a526-4d61-ae2d-d4807f9f99f3">announced plans</a> to double the fee from £200. </p>
<p>The NHS has long been a bastion of universal healthcare in Britain. It was established in 1948 with the <a href="https://www.latentexistence.me.uk/wp-content/uploads/2013/04/original-explanation-of-NHS.pdf">ambition</a> of providing healthcare, free at the point of service, for “everyone – rich, or poor, man, woman or child” to “relieve your money worries in times of illness”. In recent years, however, charges, increasing restrictions and complex guidance makes it difficult to know who has to pay for the NHS and when.</p>
<p>Historically, eligibility for free care was based on a person being “ordinarily resident in the UK”. This meant that if you moved to the UK to live and work, or you came to study, you would be entitled to free NHS care. A series of amendments to NHS regulations, <a href="http://webarchive.nationalarchives.gov.uk/20130105040917/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_081516.pdf">starting in the 2000s</a>, excluded a number of vulnerable groups from being eligible for free healthcare, including failed asylum seekers, undocumented migrants and those who had overstayed their visa. </p>
<p>Restrictions were further extended by the <a href="http://www.legislation.gov.uk/ukpga/2014/22/contents/enacted">Immigration Act 2014</a>, which excluded everyone without indefinite leave to remain. The government’s <a href="https://www.gov.uk/government/collections/nhs-visitor-and-migrant-cost-recovery-programme">Visitor and Migrant Cost Recovery Programme</a> set out how it would implement this – including strengthening the system for identifying which patients should be charged, and improving the mechanisms to recoup the costs. </p>
<p>These changes came in response to concerns over health tourism and a rising nationalist agenda. But, according to the government’s own figures, <a href="https://fullfact.org/health/health-tourism-whats-cost/">just 0.3% of the entire NHS budget</a> is attributable to deliberate health tourism. Many observers, including the British Medical Association have <a href="http://web.bma.org.uk/pressrel.nsf/wall/CF776FFE4732B83080257BD40039E80E?OpenDocument">raised concerns</a> that these reforms are “unlikely to produce enough revenue to cover the cost of setting up its own bureaucracy”.</p>
<h2>Who has to pay?</h2>
<p>As part of the cost recovery programme, in 2015, the government introduced the <a href="https://www.gov.uk/healthcare-immigration-application">Immigration Health Surcharge</a> as part of the visa application process for all those moving to the UK from outside of the European Economic Area for longer than six months. The charge was originally set at £200 a year – including for children – or £150 for students. Now it is set to double. For a family of four, it will cost £8,000 for a five-year visa. </p>
<p>For an NHS that <a href="https://theconversation.com/how-reliant-is-britain-on-eu-migrant-workers-62796">depends on migrant labour</a>, when you add the cost of the visa, the relocation process itself and the contribution made in terms of income tax, national insurance and VAT, these fees are prohibitive, overly punitive and further restrict the benefits of globalisation to the rich elite. Once they pay the charge, people are entitled to use the NHS <a href="https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide#immigration-health-surcharge-for-non-european-economic-area-nationals">in a similar way to UK residents</a>.</p>
<p>Citizens from the European Economic Area who hold a valid European Health Insurance Card, or other evidence that they are insured under the public system of a member state, are <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/666031/UPDATED_Guidance_to_Charging_Regulations_post_23_October.pdf">entitled to free NHS care</a>. Those people visiting from countries with which we have a reciprocal agreement, such as Australia or New Zealand, are similarly exempt from charging.</p>
<p>In October 2017, upfront charging for patients ineligible for free NHS care, with non-urgent conditions, became law. To determine eligibility, everyone must be asked for ID. Care for treatment that is urgent or immediately necessary remains chargeable but must be provided whether or not the person can pay. </p>
<p>The charges for treatment <a href="https://www.england.nhs.uk/wp-content/uploads/2015/05/guidance-chargeable-overseas-visitor.pdf">are at 150%</a> of the actual cost to the NHS. For those who cannot pay their bill, the use of <a href="http://www.politics.co.uk/news/2017/11/09/free-at-the-point-of-use-nhs-employs-debt-collectors-over-he">debt collectors</a> has been reported as well as <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/507694/Overseas_chargeable_patients_2016.pdf">restrictions placed on future travel</a>.</p>
<p>Those people <a href="https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide#main-messages">exempt from charges</a> include refugees, asylum seekers and victims of modern slavery. Determining whether a person falls into one of these exempt categories requires knowledge and trust at each and every healthcare encounter – including those that occur with clerical staff before the patient has even been seen by a clinician.</p>
<h2>What NHS services are charged for?</h2>
<p>Currently, care provided by a GP or in accident and emergency (A&E) departments is free of charge for everyone. However, all those patients ineligible for free NHS care now have to pay for some NHS-funded community services, including those that provide mental health care, health visiting and district nursing and services for the homeless, <a href="https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide#main-messages">among others</a>. According to <a href="https://www.gov.uk/government/collections/nhs-visitor-and-migrant-cost-recovery-programme">government plans</a>, extending charges for GP and A&E services is also on the horizon.</p>
<p>Some services do remain <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/666031/UPDATED_Guidance_to_Charging_Regulations_post_23_October.pdf">exempt from charging</a>. These include family planning services (excluding termination of pregnancy), diagnosis and treatment of some infectious diseases, community palliative care and treatment of conditions occurring as a direct result of torture, female genital mutilation, domestic violence or sexual violence. </p>
<p>But people do not walk around with a sign around their necks saying, “I have tuberculosis” or “I am a victim of torture”. Making these determinations requires time and care – which is becoming increasingly difficult in a service that is understaffed and underfunded.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-discriminatory-nhs-policy-is-bad-for-your-health-whoever-you-are-84855">New discriminatory NHS policy is bad for your health, whoever you are</a>
</strong>
</em>
</p>
<hr>
<p>The longer diagnosis is delayed, the more likely a person will suffer or even die. There is <a href="https://www.doctorsoftheworld.org.uk/news/new-research-shows-nhs-charging-is-pushing-sick-and-pregnant-migrants-away">clear evidence</a> that even the threat of charges prevents people from seeking help when they are unwell. There are already <a href="https://www.doctorsoftheworld.org.uk/Handlers/Download.ashx?IDMF=f6a9d7c2-a526-4d61-ae2d-d4807f9f99f3">reports</a> of individual harm caused by delayed diagnosis, distress from incorrect charges and concerns over infectious diseases that might go undiagnosed. Women are particularly vulnerable – excluded from maternity care and without access to free abortions. The NHS may be in crisis, but scapegoating migrants is not the solution.</p><img src="https://counter.theconversation.com/content/91344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jessica Potter receives funding from Medical Research Council UK grant number MR/M014517/1.
Jessica Potter is a member of Medact Refugee Solidarity Group and Docs Not Cops - both grass roots organisations which campaign on health issues.</span></em></p>The British government plans to double its annual charge for migrants to use the NHS.Jessica Potter, MRC Doctoral Clinical Research Fellow, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/885042017-12-11T13:55:01Z2017-12-11T13:55:01ZChanges to controversial police Mental Health Act powers may only be a sideways step<figure><img src="https://images.theconversation.com/files/197582/original/file-20171204-4053-cbdtxn.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">Tana888 / Shutterstock.com</span></span></figcaption></figure><p>Worldwide, someone dies by suicide every <a href="http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/">40 seconds</a>. More than <a href="https://www.mentalhealth.org.uk/a-to-z/s/suicide">6,000</a> people ended their own lives in the UK last year and it is estimated that for every completed suicide, there are many more attempts. </p>
<p>So perhaps it is unsurprising that around 80% of police detentions under <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/389254/Literature_Review_S135_and_S136_of_the_Mental_Health_Act_1983.pdf">Section 136</a> of the Mental Health Act relate to suicide prevention. This is the police power that allows an officer to remove someone from a public place to a place of safety for a mental health assessment if that person’s mental state appears to be placing them or others at risk. </p>
<p>The use of police cells as a “place of safety” has generated much of the <a href="http://www.telegraph.co.uk/news/2017/04/20/mental-health-provision-now-bad-patients-locked-criminals-damning/">ongoing controversy</a> this power has attracted. Last year over 2,000 of the <a href="http://www.npcc.police.uk/documents/S136%20Data%202015%2016.pdf">28,271</a> police mental health detentions were taken to custody. But as of December 11, the <a href="https://mentalhealthcop.wordpress.com/2017/11/13/paca-the-what-if-questions/">Policing and Crime Act 2017</a> has banned the use of police custody as a place of safety for anyone aged under 18, and for adults in most circumstances. The length of detention has also reduced from 72 to 24 hours and the police are now encouraged to contact a health professional before detaining someone. </p>
<p>Changes to emergency mental health provision are needed, but sadly these amendments may not greatly improve the care of those detained under Section 136, or lower the number of detentions.</p>
<h2>From police cells to hospitals</h2>
<p>One of the biggest reasons for the use of police cells has been a shortage of available health-based place of safety suites, which are generally specialised units attached to mental health hospitals. A&E, also a place of safety, has traditionally only been used when a detained person has required immediate medical attention. Now though, despite <a href="https://www.ncbi.nlm.nih.gov/pubmed/28537143">vigorous opposition</a> from some health professionals, more patients detained under Section 136 may be <a href="https://mentalhealthcop.wordpress.com/2017/10/09/paca-place-of-safety-options/">taken to emergency departments</a>. </p>
<p>While agreement has long been near universal that police custody is never an acceptable place for a vulnerable person experiencing a mental health crisis, A&E can also be a noisy and distressing environment, especially out of hours when most detentions occur. Here too, hospital staff may feel <a href="https://theconversation.com/even-nurses-arent-immune-to-the-stigma-of-suicide-66008">as ill-equipped</a> as most other people to address suicide. With many patients already facing lengthy waiting times in A&E departments, this is unlikely to manifest as a great improvement in care.</p>
<p>The BBC documentary series <a href="http://www.bbc.co.uk/programmes/b097rygd">Ambulance</a> recently showed paramedics waiting an hour for a patient detained under Section 136 who had taken an overdose to be allocated a cubicle. No additional place of safety capacity is likely to be created, so unless detentions are further reduced police cars could be set to join ambulances queuing outside hospitals.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/197585/original/file-20171204-4072-15sc8ei.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&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&E departments are already under significant pressure.</span>
<span class="attribution"><span class="source">Matt Rakowski/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>The police cannot solve the problem alone</h2>
<p>High rates of detention have contributed to suggestions that too many people were being detained because the police were using the power unnecessarily. But the reality is that Section 136 has long been used to <a href="https://theconversation.com/british-police-dealing-with-mental-health-is-a-sticking-plaster-solution-that-doesnt-get-to-the-heart-of-the-problem-84192">plug the gap</a> in mental health provision. Often detaining someone has been an officers’ only option to fulfil their <a href="https://nathanconstable.wordpress.com/2013/03/12/ahmps-rarely-have-to-talk-people-down-from-bridges-police-do/">duty to protect life</a>.</p>
<p>Solely focusing on the number of detentions does not offer a solution and the police cannot bring down detention rates without support from other services. </p>
<p>From 2012 <a href="http://www.bbc.co.uk/news/health-32739451">street triage</a> schemes, where a mental health professional joins the police in responding to calls to vulnerable people, began to emerge. These teams have broadly been welcomed for improving the care of people in need and making <a href="https://www.ucl.ac.uk/pals/research/cehp/research-groups/core/pdfs/street-triage">fewer Section 136 detentions</a>.</p>
<p>A recent University of Brighton <a href="https://www.brighton.ac.uk/_pdf/research/ssparc/final-report-s136-in-sussex.pdf">study into Section 136</a> interviewed people who had been detained before street triage was introduced. Almost all felt that the police’s decision had been appropriate but wished there had been another option. Another key finding was that several people had been detained repeatedly, some over ten times in a year, which greatly increased the total number of detentions recorded in Sussex.</p>
<h2>No single solution</h2>
<p>The issues are more complex than how appropriate a detention may be.</p>
<p>My <a href="https://www.sussexpartnership.nhs.uk/sites/default/files/documents/repeated_detention_claire_warrington_final.pdf">further research</a> is indicating that around 30% of Section 136 detentions in several parts of the south-east involve a person who has been detained before and that this is a widely recognised issue elsewhere in the country. Interviewees have given accounts of multiple traumas and ongoing hopelessness punctuated by life-saving interventions by the police, which stop a suicide but cannot address the underlying problems that have driven their desperation in the first place. </p>
<p>Dealing with the causes of extreme distress before someone reaches crisis point offers an urgently needed alternative. One programme succeeding in breaking the cycle of high frequency repeat detention is the <a href="http://www.iwcp.co.uk/news/news/shortlist-recognition-for-isle-of-wight-police-and-nhs-mental-health-collaboration-98035.aspx">Serenity Integrated Mentoring</a> project. This police-led scheme builds on the foundations of one of the first street triage models. Involving a patient, officer and mental health nurse working together, the project is demonstrating the stability that can be achieved when patients and professionals are enabled to step back from firefighting long enough to focus their efforts at pre-crisis intervention.</p>
<p>Of course, not everyone who experiences suicidal thoughts or acts on those thoughts has a mental illness. But unless more robust methods to avert suicidal crises are developed, detention rates will continue to be unacceptably high, regardless of where those detentions are located.</p>
<hr>
<p><em>Anyone who would like someone to talk to in confidence can contact the <a href="https://www.samaritans.org/how-we-can-help-you/contact-us">Samaritans</a> by calling 116 123.</em></p><img src="https://counter.theconversation.com/content/88504/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Warrington receives Doctoral Studentship funding from The Wellcome Trust. </span></em></p>Recent legal changes may not be enough to improve conditions in controversial police mental health detentions.Claire Warrington, PhD Candidate, University of BrightonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/853392017-11-07T13:22:21Z2017-11-07T13:22:21ZThe public’s knowledge of anatomy is sketchy – here’s why it matters<figure><img src="https://images.theconversation.com/files/193314/original/file-20171105-1020-iibz18.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/download/confirm/666053218?src=szM_wR-FsF2zQFavbsWN7Q-1-41&size=medium_jpg">Bangkoker/Shutterstock</a></span></figcaption></figure><p>British people don’t seem to know their armpit from their elbow. Our latest study found that only 15% of the participants could locate their adrenal glands, and only 20% knew where their spleen and gallbladder was. </p>
<p>Perhaps it’s not surprising that people struggle to identify structures in their abdomen. It’s a pretty congested space, filled with all the organs for digestion: stomach, pancreas, liver, gallbladder, 20ft of intestines and the rectum, as well as the kidneys and all the blood vessels. But understanding the abdomen is important because lots of visits to the emergency department are for problems related to these structures: <a href="https://www.nhs.uk/conditions/appendicitis/symptoms/">appendicitis</a>, <a href="https://www.nhs.uk/conditions/gallstones/symptoms/">inflamed gallbladder</a>, <a href="https://www.nhs.uk/conditions/kidney-stones/symptoms/">kidney stones</a>, <a href="https://www.nhs.uk/conditions/diverticular-disease-and-diverticulitis/">diverticulitis</a>, <a href="https://www.nhs.uk/conditions/abdominal-aortic-aneurysm/">aortic aneurysm</a>.</p>
<p>Anatomy isn’t just a subject, it is also a <a href="https://www.ncbi.nlm.nih.gov/pubmed/20069644">language</a>. When patients and healthcare professionals share this common language, consultations are smoother and patients report being more <a href="https://www.ncbi.nlm.nih.gov/pubmed/15520032">satisfied</a>. However, research has shown that when doctors <a href="https://www.ncbi.nlm.nih.gov/pubmed/17140758">over-estimate</a> their patients’ knowledge of anatomy, it can lead to worse health outcomes for the patient. </p>
<p>Although it’s not the patient’s job to have a detailed knowledge of anatomy, it can help doctors make a diagnosis more quickly and accurately.</p>
<p>Having some anatomical knowledge is part of what’s known as <a href="https://health.gov/communication/literacy/quickguide/factsbasic.htm">health literacy</a> – the ability to “obtain, process and understand health information and services needed to make an appropriate decisions”. Being health literate can help you know when something is wrong and help you decide whether to make an appointment with your doctor or go straight to an emergency department – a fairly important choice to make as winter approaches and those departments <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-crisis-a-and-e-waiting-times-record-levels-leak-bbc-data-government-failing-to-grasp-seriousness-a7570791.html">begin to come under strain</a>.</p>
<h2>Lifesaving knowledge</h2>
<p>A hint that the British public have poor knowledge of their own anatomy came from an earlier poll, conducted by Prostate Cancer UK. The charity found that <a href="https://prostatecanceruk.org/about-us/news-and-views/2016/4/almost-1-in-5-men-lethally-ignorant-they-even-have-a-prostate-new-survey-finds">more than half</a> of the 2,000 men they surveyed did not know where their prostate was. Alarmingly, 17% of the men surveyed didn’t know they had a prostate. Only <a href="https://journals.rcni.com/doi/abs/10.7748/ns.30.40.17.s20">8%</a> knew what it did.</p>
<p>If you’re a man, knowing where your prostate is, is fairly crucial. In 2014, just under <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer">47,000</a> men were diagnosed with prostate cancer, and over 11,000 men died from the disease.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193315/original/file-20171105-1017-g5bbeg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nearly one in five men don’t know that they have a prostate (it’s the yellow bit).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/458875147?src=9cHzrKo0D4K39vqJipLTMg-1-89&size=medium_jpg">Anatomy Insider/Shutterstock</a></span>
</figcaption>
</figure>
<p>For our own study, we asked 63 members of the public, ranging in age from eight to 74 to place 20 body organs and structures onto a map of the body. Thankfully, all of the participants knew <a href="http://dx.doi.org/10.1002/ase.1746">where their brain was located</a>. They were also quite good at identifying the cornea and the biceps muscle. But when it came to the abdomen, things got worse. Some people located the liver on the wrong side, adrenal glands in the neck, stomach in a variety of locations and diaphragm in the wrong place.</p>
<p>Men were better at identifying specific muscles than women, but not at internal organs, where females were better. </p>
<p>We also asked the participants if they’d visited a healthcare professional in the last seven days – ten said that they had. This had two objectives. The first was to see if people could recall what they had been informed about. Our results suggested they couldn’t. The second was to see if going home and using the internet after their consultation would make them better at answering questions about their anatomy. It didn’t. </p>
<p>I was relieved to find that healthcare professionals performed significantly better than the rest. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193312/original/file-20171105-1046-11fbqgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cluttered space.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/495646264?src=PDwMwu4woRUzdi2s2e5HoQ-1-41&size=medium_jpg">Tefi/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Finally, there was no significant difference in performance based on academic qualifications. We saw a peak in the knowledge level around the age of 40, which coincides with <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00620-6/fulltext?rss%3Dyes">increased</a> GP referral rates, suggesting that this is the age bracket where people begin to take more notice of their anatomy. </p>
<p>Reassuringly, pre-adolescent children also fared well. There is no formal anatomical education in the UK for children in this age group, but there is obviously a thirst for knowledge about the subject, given how well they performed in the study. </p>
<p>But we really could do more to teach basic anatomy in primary and secondary school. It may help people live longer, healthier lives, and it would certainly make doctors’ lives easier.</p><img src="https://counter.theconversation.com/content/85339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Taylor is affiliated with the Anatomical Society</span></em></p>Basic anatomical knowledge can save lives.Adam Taylor, Director of the Clinical Anatomy Learning Centre & Senior Lecturer in Anatomy, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/609082016-06-13T11:40:48Z2016-06-13T11:40:48ZThe truth about migrants and the NHS<figure><img src="https://images.theconversation.com/files/126339/original/image-20160613-29238-xigwuk.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="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=doctors%20waiting%20room&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=148769519">Robert Kneschke/Shutterstock.com</a></span></figcaption></figure><p>Announcing her decision to defect from Vote Leave to the Remain campaign, Conservative MP Dr Sarah Wollaston claimed: <a href="http://www.thetimes.co.uk/article/comment-leave-s-health-claims-are-shameful-x75m2hm2m">“If you meet a migrant in the NHS, they are more likely to be treating you than ahead of you in the queue”</a>. How right she is. </p>
<p>Migrants fall into two groups: those who are visiting temporarily, and those who are resident. People from the first group who use the NHS have been dubbed “medical tourists”, taking advantage of free health care. But such visitors now <a href="https://theconversation.com/is-it-worth-making-health-tourists-pay-for-nhs-care-52607">have to pay</a> for the care they receive. </p>
<p>Visa and immigration applicants from outside the European Economic Area have to pay an annual “health surcharge” if they plan to stay in the country for more than six months. Those staying less than six months have to pay 150% of the cost of hospital care. EU visitors have to show their European Health Insurance Cards when using the NHS so that their home countries can be billed for their care. These arrangements mean that visitors are no more a drain on the NHS than they are on restaurants or West End theatres: they’re paying for the services they receive.</p>
<p>Migrants that become “ordinarily resident” in the UK are entitled to use the NHS on the same terms as people born here. But they are less likely than the native population to do so. People who migrate tend to be younger and healthier than native populations. Older people and those with disabilities and severe illness are less likely to move, apart from in extreme circumstances. This underpins a longstanding epidemiological phenomenon, called the <a href="http://www.euro.who.int/__data/assets/pdf_file/0008/80468/Eurohealth13_1.pdf">“healthy migrant effect”</a>. </p>
<p>This is backed up by evidence from NHS data. A University of Oxford study using local authority immigration data and NHS hospital data found that areas with more immigration had lower waiting times for <a href="http://www.bsg.ox.ac.uk/research/working-paper-series/working-paper-005">outpatient referrals</a>. On average, a 10% increase in the share of migrants living in a local authority reduced waiting times by nine days. The authors find no evidence that immigration affects waiting times in A&E and in elective care. </p>
<p>Migrants are less likely to be ill, and also more likely to be working. The Institute for Public Policy Research recently reported that EU migrants have <a href="http://www.ippr.org/publications/free-movement-and-the-eu-referendum">higher employment rates</a> than UK nationals. The employment rate of UK nationals is 74%, slightly below the 75% for migrants from EU15 countries (those in the EU before 2004). Employment rates for migrants from newer member states is 83 per cent, although they tend to be in lower-skilled and lower-paid work. </p>
<p>If migrants are working, they’ll be paying income tax and making national insurance contributions. These are the sources of NHS funding. This means that resident migrants are likely to be paying their share towards the costs of the NHS. </p>
<p>So immigrants to the UK are more likely to be healthy and more likely to be working. The opposite may be the case for emigrants from the UK. Around 1.2m Britons live in other <a href="http://www.ippr.org/publications/free-movement-and-the-eu-referendum">EU countries</a> – mainly in Spain, Ireland, France and Germany. While some of these emigrants have moved to work, many have chosen to retire overseas. And retirees are more likely to make use of the health system, simply because they are older. On balance, then, the UK benefits from “healthy immigrants”, while exporting “unhealthy emigrants” for other health systems to deal with.</p>
<h2>Are you likely to be treated by a migrant?</h2>
<p>Not only are migrants more likely to working, they are very likely to be working in the NHS. According to statistics collected by the <a href="http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT">Organisation for Economic Co-operation and Development</a>, the NHS is more reliant on “foreign trained” staff than are other EU countries (see figure). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126182/original/image-20160610-29216-1l86deo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In 2014, 28% of doctors working in the UK were trained abroad, compared with an average of just 9% across the other countries. Thirteen percent of nurses are foreign trained, compared with 2% elsewhere. Some of these are trained outside the EU, but <a href="http://www.gmc-uk.org/doctors/register/search_stats.asp">11% of doctors</a> and <a href="https://fullfact.org/immigration/immigration-and-nhs-staff/">4% of nurses</a> working in the NHS are from other European Economic Area countries (EU plus Iceland, Liechtenstein and Norway).</p>
<p>The Public Accounts Committee has been very critical of <a href="https://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/inquiries/parliament-2015/nhs-staff-numbers-15-16/">evident failures</a> in NHS workforce planning. This has meant that overseas recruitment has been essential to fill shortfalls in staffing. Leaving the EU will make the situation worse, particularly in shortage specialties such as emergency care and general practice, severely constraining our ability to recruit overseas staff.</p>
<p>The Leave campaign claims that Brexit will allow us greater border control, above and beyond the higher entry barriers the UK already has by not being part of the Schengen area. These restrictions are likely to reduce immigration from other EU countries, which may reduce use of the NHS, but will also reduce NHS income received directly from such users or via taxation.</p>
<p>More worryingly, Brexit would reduce access to a pool of staff that we need to draw from to address NHS workforce shortages. There also may be adverse consequences for UK emigrants and holidaymakers, if the other EU countries retaliate by making it more difficult to retire abroad or ask us to surrender our European Health Insurance Cards.</p><img src="https://counter.theconversation.com/content/60908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Bloor has received project funding from the National Institute for Health Research, the Department of Health's Policy Research Programme and the European Union. The views expressed are her own. </span></em></p><p class="fine-print"><em><span>Andrew Street has recived project funding from the National Institute of Health Research, the Department of Health's Policy Research Programme, and the European Union. The views expressed are his own.</span></em></p>Migrants have been accused of ‘clogging up the NHS’. But where would the NHS be without them?Karen Bloor, Professor of Health Economics and Policy, University of YorkAndrew Street, Professor, Centre for Health Economics, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/594792016-05-17T10:04:10Z2016-05-17T10:04:10ZAre NHS patients really more likely to die at weekends? Here are the facts<figure><img src="https://images.theconversation.com/files/122698/original/image-20160516-15924-1qzze24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People admitted to hospital on the weekend tend to be sicker.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=kSbwT8GtuWbq0uWOvABszA-1-1&clicksrc=download_btn_inline&id=406082761&size=medium_jpg&submit_jpg=">spatuletail/shutterstock.com</a></span></figcaption></figure><p>Jeremy Hunt, secretary of state for health, and Philippa Whitford, a Scottish surgeon and MP, had a row about seven-day services during Hunt’s appearance before the Health Select Committee on <a href="http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/spending-review-health-minister-evidence-15-16/">May 9</a>. The issue has also featured in the acrimonious dispute about the junior doctors’ contract <a href="http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract">negotiations</a> which reopened on the same day. </p>
<p>Hunt and Whitford tussled about the quality and interpretation of evidence about weekend mortality rates and whether we need a seven-day hospital service to set things right. Hunt referred to <a href="https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality">evidence</a> compiled by the Department of Health. It comprises eight studies, of which only four are peer-reviewed articles, the others being reports. Hunt claims that these studies prove that hospital mortality rates are higher for those admitted over the weekend than during the week. Other studies have also found a “weekend effect”. But the effect is smaller when accounting for how sick patients are and it isn’t evident for all conditions. For instance, there is no weekend effect for <a href="http://bit.ly/1TgrYRj">stroke care</a>.</p>
<p>Whitford didn’t dispute the existence of a weekend effect, but said the higher weekend mortality rate is not because more people are dying. Rather the rate is higher because fewer people are admitted at the weekend and they tend to be sicker. This was the conclusion drawn by authors of a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">study</a> published a few days before the committee hearing. Unlike other studies, this made use of both accident and emergency and hospital data. It found a weekend effect only among those admitted to hospital, and it was mainly because they are sicker. The authors conclude that expanding services to seven days a week may cause the mortality rate to fall, but most likely because admissions will increase, not because fewer people will die.</p>
<h2>Hunt’s solution</h2>
<p>Hunt brought out a different message from the same study, saying that more stringent admission criteria shouldn’t be applied at the weekend. He wants four <a href="http://www.parliament.uk/documents/commons-committees/Health/Correspondence/2015-16/Letter-from-the-Secretary-of-State-for-Health-to-the-Chair-on-seven-day-NHS-hospital-services.pdf">priority clinical standards</a> to be met every day for all patients requiring urgent and emergency care. All emergency admissions should have a thorough assessment by a consultant within 14 hours of arrival at hospital; everyone in hospital should have access to consultant-directed diagnostic tests, and to consultant-directed interventions; and high dependency patients must be seen and reviewed by a consultant twice daily, and once a day after transfer to a general ward.</p>
<p>Notably, these standards all relate to the presence of consultants (senior doctors). But, to meet them, a whole range of diagnostic and support services must be made available as well as clinical cover provided by junior doctors. Junior doctors, however, object to plans to consider Saturday a <a href="https://fullfact.org/health/junior-doctors-pay-short-introduction-dispute/">normal working day</a> for calculating their pay.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Seven-day service is a central feature of the dispute about the junior doctors’ contract.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=7rfstA2OwnA3TqQS_KUN3g-1-27&clicksrc=download_btn_inline&id=412141594&size=medium_jpg&submit_jpg=">Ms Jane Campbell / Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The four standards were chosen as priorities by NHS England and the Academy of Medical Royal colleges set out by NHS England’s <a href="https://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf">Seven Days a Week Forum</a>. These are being rolled out across the country, the aim being that they will have been adopted by all hospitals by March 2020.</p>
<p>The standards have already been implemented in some hospitals. The day after the Hunt-Whitford debate, a <a href="http://bit.ly/22dn4tW">study</a> was published in The Lancet comparing hospitals that have implemented the standards with those that have not. This found that patients admitted on Sundays get less than half the attention from consultants than those admitted on Wednesdays. But it also found that variation across hospitals in how much time consultants spend with patients is not associated with the hospital’s mortality rate. So it cannot be said that mortality rates can be reduced simply by increasing consultant cover.</p>
<h2>Where does this leave us?</h2>
<p>Clearly, more evidence is required. First, it remains unclear whether the weekend effect is just a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">statistical artefact</a> or whether there is a real problem with a clear cause. </p>
<p>Second, studies should capture a broader array of <a href="http://bit.ly/1YuC6cw">outcomes</a> than just mortality. Even if seven-day services don’t reduce mortality rates, patients may still be better off.</p>
<p>Third, we need to know the costs of the policy. On May 11, the Public Accounts Committee offered <a href="http://bit.ly/1ZEdLBt">harsh criticism</a>, saying: </p>
<blockquote>
<p>no coherent attempt has been made to assess the headcount implications of major policy initiatives such as the seven-day NHS … It beggars belief that such a major policy should be advanced with so flimsy a notion of how it will be funded…</p>
</blockquote>
<p>Finally, implementation of seven-day services was a <a href="https://www.gov.uk/government/news/prime-minister-pledges-to-deliver-7-day-gp-services-by-2020">manifesto commitment</a>. But mortality rates for patients admitted <a href="http://bit.ly/1TgrYRj">overnight</a> are higher than for those admitted during the day; and they are higher for <a href="http://www.nets.nihr.ac.uk/projects/hsdr/11200439">poorer</a> than richer patients. If we want to reduce hospital mortality, perhaps policy could be directed at correcting these differences as well.</p><img src="https://counter.theconversation.com/content/59479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Street receives funding from the National Institute of Health Research and the Department of Health's Policy Research Programme but the views expressed are his own.</span></em></p>While politicians and doctors argue over the data on the weekend effect, it’s important to remember that there are other ways to reduce hospital deaths.Andrew Street, Professor, Centre for Health Economics, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/505462015-11-12T11:56:57Z2015-11-12T11:56:57ZCutting hospital death rate at weekends is achievable – but keep a close eye on the number of admissions<figure><img src="https://images.theconversation.com/files/101572/original/image-20151111-9374-orv1h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More patients die at weekends</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-205406395/stock-photo-intensive-care-unit.html?src=dt_last_search-1">www.shutterstock.com</a></span></figcaption></figure><p>In a recent letter to junior doctors, secretary of state Jeremy Hunt again argued that “tackling higher mortality rates at weekends” was of <a href="http://www.telegraph.co.uk/news/health/11968014/Jeremy-Hunt-Junior-doctors-have-been-misled-by-the-BMA.html">utmost priority</a> and that he would be pushing pay reform through to tackle the “link between higher weekend death rates and reduced weekend services”. </p>
<p><a href="https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality">Six studies</a> have found a link between higher weekend death rates and a reduced weekend service, the most <a href="http://www.bmj.com/content/351/bmj.h4596">recent</a> of which found that 11,000 more people die each year if admitted over the extended weekend, from Friday to Monday, compared with those admitted on midweek days. </p>
<p>Hunt’s solution is to increase weekend cover, with more senior consultants on hand to back up junior doctors, together with a full range of diagnostic and support services. His plan will work. By increasing weekend staffing levels, in time there will be a smaller difference between midweek and weekend mortality rates. But the gap may not close for the reason Hunt intends. </p>
<h2>Closing the gap</h2>
<p>The figure of 11,000 excess deaths was calculated by comparing the rate of deaths to admissions over the weekend with the midweek rate. There are two ways by which a rate can be reduced. One is to reduce the number of deaths of those admitted over the weekend. This is what Hunt wants. It may be that people are dying unnecessarily because there aren’t enough staff to care for them. If so, making more staff available at the weekend should help save lives. </p>
<p>But the weekend mortality rate can also be reduced by increasing the number of weekend admissions. If more people are admitted, then the weekend mortality rate would fall, even if the same number of people were still to die.</p>
<p>At the moment, simply because fewer staff are available, the chance of being admitted over the weekend is lower than <a href="https://www.nao.org.uk/wp-content/uploads/2013/10/10288-001-Emergency-admissions.pdf">during midweek</a>. And because the chance of admission is lower, those people that are admitted at the weekend <a href="http://www.bmj.com/content/351/bmj.h4596">tend to be sicker</a> than those admitted during the week. And, of course, sicker people are more likely to die. </p>
<p>To some extent, the higher likelihood of dying is taken into account in the calculation of mortality rates. But the calculation is imperfect because there is limited information about how sick patients are. Taking account of this missing information has been shown to be critical in the analysis of <a href="http://www.sciencedirect.com/science/article/pii/S0167629613000908">hospital readmission rates</a>, and efforts are being made to do something similar in analysing admission from <a href="http://www.nets.nihr.ac.uk/projects/hsdr/1212848">accident and emergency departments.</a> </p>
<p>Probably both the number of deaths and the number of admissions will change as a result of more staff being available at the weekend. So Hunt is likely to achieve his goal. By making more staff available, the weekend mortality rate is likely to fall. But the reduction is likely to be driven not so much by a fall in the number of deaths but mainly by an increase in weekend admissions. </p>
<h2>Saving lives</h2>
<p>This wouldn’t be an altogether desirable achievement. For one thing, reductions in the weekend mortality rate will come at the expense of efforts to <a href="https://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions.pdf">reduce emergency admissions</a>. For another, it may detract from more <a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3207/abstract">cost-effective</a> ways to save lives. </p>
<p>It turns out that hospitals have been getting better at keeping people alive over the past decade. This can be seen from data about hospital death rates published by the <a href="https://indicators.ic.nhs.uk/webview/">Health and Social Care Information Centre</a>, the latest release covering 2003-13. </p>
<p>There have been significant improvements in survival in the 30 days following coronary artery bypass graft, elective surgery and treatment for heart attack and leg fracture. But the most dramatic improvement has been in stroke survival, especially following the launch of the <a href="https://www.nao.org.uk/wp-content/uploads/2010/02/0910291.pdf">national stroke strategy</a> in December 2007.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=482&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=482&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=482&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=606&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=606&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101688/original/image-20151112-9388-10nbpm3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=606&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Age standardised deaths per 100,000 within 30 days of a hospital procedure.</span>
<span class="attribution"><span class="source">derived from HSCIC https://indicators.ic.nhs.uk/webview/</span></span>
</figcaption>
</figure>
<p>The trends in survival are cause for celebration. When it comes to keeping people alive, the NHS has been making big improvements for quite some time. These improvements have not happened by chance, but reflect the success of efforts such as the national stroke strategy to improve prevention, diagnosis and treatment. A similar strategy is needed to address higher weekend mortality, underpinned by a better understanding of its causes and a review of how these might be addressed. Without this, the weekend mortality rate might well fall, but we’ll be no better off as a consequence.</p><img src="https://counter.theconversation.com/content/50546/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>Andrew Street receives funding from the National Institute of Health Research and the Department of Health's Policy Research Programme but the views expressed are his own.</span></em></p>Jeremy Hunt’s solution to cutting deaths in hospitals at the weekend is to increase staff levels. But is it just a fudge?Andrew Street, Professor, Centre for Health Economics, University of YorkLicensed as Creative Commons – attribution, no derivatives.