tag:theconversation.com,2011:/africa/topics/healthcare-1683/articlesHealthcare – The Conversation2024-03-04T13:41:25Ztag:theconversation.com,2011:article/2246602024-03-04T13:41:25Z2024-03-04T13:41:25ZHospital privatisation is linked with worse quality care for patients – new research<figure><img src="https://images.theconversation.com/files/578902/original/file-20240229-24-vgcipq.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6144%2C3449&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Privatisation may not necessarily benefit patients.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/different-people-waiting-row-hospital-reception-2169645853">DC Studio/ Shutterstock</a></span></figcaption></figure><p>The NHS is in a critical state. The continued consequences of the pandemic and <a href="https://www.independent.co.uk/news/health/nhs-waiting-list-rishi-sunak-b2504164.html">long waits for treatment</a> mean that people are facing more difficulties than ever accessing the care they need. A growing number of people are even <a href="https://www.phin.org.uk/news/phin-private-market-update-december-2023">paying</a> to get treatment. </p>
<p>There’s a clear need to reform the NHS – and it’s likely this will be a huge issue in the upcoming election. The next government, whoever they are, will be under pressure to urgently address these issues within the NHS.</p>
<p>While <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-9-43">increasing spending</a> may be one way to address these issues, others have argued that <a href="https://www.theguardian.com/society/2023/jul/05/tony-blair-urges-expanded-role-for-private-sector-as-nhs-turns-75">outsourcing NHS services</a> to for-profit providers (privatisation) would help make services more efficient and improve care</p>
<p>But outsourcing may solve one problem while creating others. A recent review I published with some colleagues has found that while privatisation may allow hospitals to cut their costs, it’s also linked with <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(24)00003-3/fulltext">worse quality care for patients</a>.</p>
<p>To conduct our review, we brought together peer-reviewed research on the effects of outsourcing on quality of care. Our review analysed 13 studies from eight high-income countries, including the US, Germany, Canada and South Korea.</p>
<p>Importantly, we only included studies which tracked outcomes before and after outsourcing and could compare outcomes to areas or hospitals with fewer outsourced services. We did this so that our research was directly comparing the effect of privatising care on public services, and not just looking at how care in both the public and private sectors differed.</p>
<p>We found that hospitals who converted from public to private ownership tended to make higher profits than public hospitals. This was achieved by reducing staff numbers and taking on patients who would be considered more profitable (such as those with more generous insurance coverage). Outsourcing also tended to correspond with fewer staff members per patient – including fewer cleaning staff. </p>
<p>Privatised hospitals also tended to cut back on more qualified members of staff. For example, in the US, there was a substantial reduction in the number of qualified nurses employed after a hospital was privatised, when compared with the number employed in public hospitals. But while numbers of most other types of staff were reduced after privatisation, doctors’ numbers remained the same. The studies often concluded that cutting qualified staff was the result of incentives to increase profits and reduce costs.</p>
<figure class="align-center ">
<img alt="A nurse speaks with a patient in the waiting room." src="https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578905/original/file-20240229-30-xs9fpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Privatised hospitals would reduce nurse numbers to reduce costs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/busy-reception-desk-many-patients-waiting-2185665787">DC Studio/ Shutterstock</a></span>
</figcaption>
</figure>
<p>We also found that increases in outsourcing frequently corresponded with worse health outcomes for patients. </p>
<p>Two studies, one conducted in England and one in Italy, both found that increases in the proportion of outsourced care corresponded with higher avoidable death rates (for example, deaths from curable respiratory diseases or surgical accidents) than before outsourcing took place. While neither study could be certain the reasons for higher death rates, they both concluded that quality of care was the most plausible reason. Further research is needed to be sure that the decline in health outcomes is specifically due to changes in accessibility, inequitable treatment or just poorer performing hospitals in the private sector.</p>
<p>When it came to how easily patients could access healthcare services, results were mixed. Two studies that assessed hospital conversions from public to private in the US found that care became less accessible after going private – either because the hospitals became more selective of which patients they treated or because the number of services provided in the privatised hospitals was cut.</p>
<p>But one study in Croatia found that when primary care practices came under private ownership, patients saw benefits. Patients started receiving more precise appointment times and had the opportunity to access healthcare through new means – such as out-of-hours telephone calls. </p>
<p>Overall, this is a difficult area to evaluate as there’s not a huge range of evidence. But, based on the best evidence available, our review consistently finds that privatising healthcare services corresponds with worse quality care and worse patient outcomes.</p>
<p>Evidence from other care sectors, such as <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(22)00040-X/fulltext">long-term adult care</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0277953622006293">children’s social care</a>, have also shown negative outcomes for patients when these services are privatised.</p>
<h2>What this all means</h2>
<p>In light of our findings, and in the context of the current NHS crisis, how should the next UK government’s healthcare agenda look? We would suggest that a progressive agenda would aim to remove the dependency of healthcare services on private market provision, avoid further outsourcing and instead fund publicly run services.</p>
<p>Outsourcing has been a popular policy posed by governments of different political stripes for decades. And, with an election looming, both <a href="https://www.theguardian.com/commentisfree/2022/dec/08/people-in-pain-private-hospitals-nhs">Labour</a> and the <a href="https://www.theguardian.com/society/2023/aug/04/rishi-sunak-warned-of-concerns-over-nhs-private-sector-partnerships">Conservative parties</a> show no signs of changing their tunes.</p>
<p>But the evidence which is starting to emerge shows that more often than not privatisation would be a mistake.</p><img src="https://counter.theconversation.com/content/224660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Goodair receives funding from Wellcome Trust 221160/Z/20/Z.</span></em></p>Our review shows that evidence to support further privatisation of healthcare services is weak.Benjamin Goodair, Postdoctoral Researcher, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2227812024-02-12T16:31:40Z2024-02-12T16:31:40ZGiving birth in Sweden: outcomes are worse for foreign-born mothers<figure><img src="https://images.theconversation.com/files/574646/original/file-20240209-30-wshqpn.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5055%2C3359&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-father-holding-newborn-baby-son-627702491">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>Sweden has consistently reported some of the lowest rates of maternal and child mortality in the <a href="https://www.who.int/data/gho/data/themes/topics/topic-details/mca/maternal-and-newborn---mortality-causes-of-death">world</a>. Unfortunately, these achievements don’t extend to foreign-born mothers who face higher risks for all forms of negative pregnancy <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.0001-6349.2005.00686.x">outcomes</a>.</p>
<p>The COVID pandemic was a strong reminder of the gaping health inequities when providing care to these women. Foreign-born mothers reported higher rates of infection, <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.14552">intensive care admission</a>, preterm birth, underweight babies and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9111112/pdf/BJO-129-1361.pdf">stillbirths</a> compared with Swedish-born mothers.</p>
<p>Afra (not her real name) is one such case. Her baby died in the womb soon after she caught COVID in her third trimester. She grieved how utterly the healthcare system had failed her when she was referred to the university hospital for a consultation. “No one told me that COVID could be dangerous for the baby,” she told me. “I asked my midwifery-centre, and they said nothing. I was not even advised to take the vaccine!”</p>
<p>Afra’s story is one of many that highlights the difficulties foreign-born mothers face in the Swedish healthcare system. Despite being <a href="https://www.norden.org/en/info-norden/pregnancy-and-childbirth-sweden">universally available and free</a> for all mothers, why is one of the leading healthcare systems in the world failing to protect its foreign-born citizens?</p>
<p>The reason is simple. It lies in the very fabric of the Swedish healthcare system, namely the principle of being impartial and providing the same resources for all. The system does not recognise that, due to their socioeconomic status and ethnicity, foreign-born mothers require additional resources to achieve the same outcomes as Swedish-born mothers.</p>
<p>Almost one-third of all Swedish births are from <a href="https://www.europeanjournalofmidwifery.eu/Midwives-communication-with-non-Swedish-speaking-women-giving-birth-A-survey-from,148159,0,2.html">foreign-born mothers</a>. This number has increased from the 1970s, where only 11% of all births were from <a href="https://www.europeanjournalofmidwifery.eu/Midwives-communication-with-non-Swedish-speaking-women-giving-birth-A-survey-from,148159,0,2.html">non-native mothers</a>. With this growing number, it is high time to dissect the reasons for these inequities and find solutions to address them.</p>
<p>For example, the tools already at our disposal could be used to identify and map these inequities and where they are occurring. The evidence-based guidelines used in the Swedish healthcare system are backed by several high-quality registers that document patient outcomes at the population level. </p>
<p>Childbirth care is documented by the <a href="https://www.socialstyrelsen.se/en/statistics-and-data/registers/national-medical-birth-register/">Swedish Medical Birth Register</a>, which has been collecting maternal, medical and neonatal data for almost five decades. The register covers 99% of all births in Sweden – but hardly any data specific to socioeconomics, such as race or ethnicity, is collected. </p>
<p>Of the few variables collected, country of birth is one and job status is the other. This means that the most valuable tool available to maternal healthcare professionals is essentially impaired from identifying how health inequities can affect birth outcomes.</p>
<h2>Language barriers</h2>
<p>Communication barriers due to a lack of proficiency in the Swedish language in foreign-born mothers is a large challenge in this regard. Many maternal healthcare professionals, including midwives, report this as a huge issue and struggle to adequately understand <a href="https://www.europeanjournalofmidwifery.eu/Midwives-communication-with-non-Swedish-speaking-women-giving-birth-A-survey-from,148159,0,2.html">non-Swedish speaking mothers</a>. </p>
<p>In high-risk situations, like during an emergency caesarean section, such communication barriers may be critical and can even cost lives. </p>
<p>Also, there is limited understanding of how these language barriers affect foreign-born mothers’ overall understanding of the care they are receiving and their experiences of the quality of care provided. Future research would be key to understanding this knowledge gap.</p>
<p>An interesting solution is the use of what are known as “cultural doulas” to help increase healthcare availability and support to foreign-born mothers through their pregnancies, especially during childbirth. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/34222838/">Doulas</a> are people without specific medical training, but whose cultural and language proficiency can be involved in a woman’s pregnancy and childbirth to give emotional, social and psychological support. They have been found to reduce caesarean section rates and improve the overall <a href="https://europepmc.org/article/med/16714912">quality of care</a>.</p>
<p>Of course, not everyone is keen on this idea. With an already heavily taxed population, and the healthcare system losing many millions of Swedish kronor per year, maternal healthcare and research have never been high on the priority list. </p>
<p>But if these changes were made, Swedish maternal healthcare could contribute significantly to improving outcomes for foreign-born mothers and their babies. By addressing this issue head-on, we can ensure that all mothers receive the comprehensive care they deserve, regardless of their origins.</p><img src="https://counter.theconversation.com/content/222781/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mehreen Zaigham receives funding from the Swedish Research Council Grant 2022–00208. </span></em></p>About one in three Swedish births are from foreign-born mothers.Mehreen Zaigham, Associate Professor, Lund University, Sweden, Lund UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2128552024-01-04T13:45:22Z2024-01-04T13:45:22ZSeeing the human in every patient − from biblical texts to 21st century relational medicine<figure><img src="https://images.theconversation.com/files/564308/original/file-20231207-19-2ew23e.jpg?ixlib=rb-1.1.0&rect=9%2C3%2C2108%2C1406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Making patients feel seen and heard -- not just "treated."</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/clinical-doctor-giving-test-results-to-patients-royalty-free-image/1062186846?phrase=doctor+patient&searchscope=image%2Cfilm&adppopup=true">Tom Werner/Digital Vision via Getty Images</a></span></figcaption></figure><p>Patients frequently describe the U.S. health care system as impersonal, corporate and fragmented. One study even called <a href="https://doi.org/10.1001/archinte.168.17.1843">the care delivered to many vulnerable patients</a> “inhumane.” Seismic changes caused by the COVID-19 pandemic – particularly the shift to telehealth – only exacerbated that feeling.</p>
<p>In response, many health systems now emphasize “<a href="https://doi.org/10.1016/j.jradnu.2023.02.005">relational medicine</a>”: care that purports to center on the patient as a human being. Physician <a href="https://www.urmc.rochester.edu/people/112358510-ronald-mark-epstein">Ronald Epstein</a> and health communication researcher <a href="https://liberalarts.tamu.edu/communication/profile/richard-l-street-jr/">Richard Street</a> describe “<a href="https://doi.org/10.1370/afm.1239">patient-centered care</a>” as advocating “deep respect for patients as unique living beings, and the obligation to care for them on their terms.”</p>
<p>In 15 years as <a href="https://www.religiousstudies.pitt.edu/people/jonathan-weinkle-md-faap-facp">a primary care physician</a>, I have seen the effects of dehumanizing medical care – and the difference it makes when a patient feels they are being respected, not just “treated.” </p>
<p>Though “relational medicine” may be a relatively new phrase, the basic idea is not. Seeing each person before you as someone of infinite value is fundamental to many faiths’ beliefs about medical ethics. In my own tradition, Judaism, “person-centered care” has roots in <a href="https://www.sefaria.org/Genesis.1.28?lang=bi&aliyot=0">the biblical Book of Genesis</a>, where the creation story teaches that “God created the Human in God’s own image.” As <a href="https://www.chatham.edu/academics/graduate/physician-assistant-studies/faculty/jonathan-weinkle.html">a medical educator,</a> I teach students how to turn these abstract ideas into concrete clinical skills.</p>
<h2>Divine dignity</h2>
<p>Traditional Jewish law sets rules that shape my understanding of these skills. As the influential French sage Rashi wrote in an 11th century commentary on the Bible, <a href="https://www.sefaria.org/Leviticus.19.16?lang=bi&aliyot=0&p2=Rashi_on_Leviticus.19.17.1&lang2=bi&w2=all&lang3=en">it is forbidden to publicly embarrass a person</a> “so that their face turns white,” even while rebuking them. For doctors today, this might mean taking care not to <a href="https://doi.org/10.2337/diaclin.34.1.44">inflict shame on a person with a stigmatized illness</a> like substance use <a href="https://theconversation.com/what-does-weight-inclusive-health-care-mean-a-dietitian-explains-what-some-providers-are-doing-to-end-weight-stigma-207710">or obesity</a>.</p>
<p>The Bible <a href="https://www.sefaria.org/Exodus.22.24?lang=bi&with=all&lang2=en">forbids wronging</a> <a href="https://www.sefaria.org/Bava_Metzia.60a.1?lang=en&with=all&lang2=en">or abusing strangers</a> not once, not twice, but 36 times – a reminder not to “other” people or obscure their basic humanity. A similar value appears in the <a href="https://www.jstor.org/stable/44449883">18th century Physician’s Prayer</a>, written by the German-Jewish physician Marcus Hertz, who states, “In the sufferer, let me see only the human being.”</p>
<p>American Rabbi <a href="https://www.nytimes.com/2014/12/26/us/harold-m-schulweis-progressive-rabbi-is-dead-at-89.html">Harold Schulweis</a> used the concept of “covenant” – a holy, mutual agreement – as <a href="https://catalogue.nla.gov.au/catalog/1859917">a model for the bond between physician and patient</a>, working toward a common goal. This idea inspired my own book, “<a href="https://healthylearning.com/healing-people-not-patients-creating-authentic-relationships-in-modern-healthcare-1/">Healing People, Not Patients</a>.”</p>
<p>Similar connections between medicine, respect and religion are found in other traditions, as well. A 1981 <a href="https://www.encyclopedia.com/science/encyclopedias-almanacs-transcripts-and-maps/islamic-code-medical-ethics-kuwait-document">Islamic code of medical ethics</a>, for instance, considers the patient the leader of the medical team. The doctor exists “for the sake of the patient … not the other way round,” it reminds practitioners. “The ‘patient’ is master, and the ‘Doctor’ is at his service.” </p>
<h2>Seeing and hearing the whole patient</h2>
<p>In undergraduate classes that I teach for future health professionals at the University of Pittsburgh, we focus on communication skills to foster dignified care, such as setting a shared agenda with a patient to <a href="https://doi.org/10.1111/j.1525-1497.2005.40266.x">align their goals and the provider’s</a>. Students <a href="https://www.matthewsbooks.com/productdetail.aspx?pid=6221TRZ8106&close=false">also read “Compassionomics</a>,” by medical researchers <a href="https://preprofessionalstudies.nd.edu/people/stephen-trzeciak/">Stephen Trzeciak</a> and <a href="https://cmsru.rowan.edu/faculty-profiles/emergency-medicine/teaching-faculty/mazzarelli-anthony.html">Anthony Mazzarelli</a>, which aggregates the data showing caring’s impact on the well-being of patients and providers alike.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in a white medical coat leans forward, seated, as she talks seriously with a seated boy in a green t-shirt." src="https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564321/original/file-20231207-17-v5t2n4.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"></a>
<figcaption>
<span class="caption">Respectful care isn’t just ‘nice’ – it’s more effective.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-doctor-talking-to-boy-in-exam-room-royalty-free-image/1293518268?phrase=doctor+patient&searchscope=image%2Cfilm&adppopup=true">The Good Brigade/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<p>However, even health professionals steeped in these practices can encounter people whose humanity they struggle to see. Students wrestle with <a href="https://doi.org/10.1056/NEJM197804202981605">a classic article about “the hateful patient</a>” and practice an exercise called <a href="https://doi.org/10.7326/M13-0995">the “second sentence</a>.” This asks providers to look beyond their first impressions of a patient they might have trouble treating with compassion, imagining a “second sentence” that humanizes the person in front of them.</p>
<p>The course evaluation is based on a project in which students interview a friend, relative or neighbor about their experience of illness and care. Ultimately, they identify one element of the person’s care that could have been improved by attending more to the person’s individual needs and listening to their story. </p>
<p>One student recounted her brother’s experience after he suffered a serious sports injury. The trauma team followed protocol precisely, but this meant that they did not register him screaming in pain, telling them that what they were doing was making him feel worse. Only in the hospital did doctors discover that those screams were a clue to a specific injury that should have received radically different care in the field, which could have been caught earlier had the team attended more closely to his words. His sister explored the medical literature on <a href="https://doi.org/10.1177/0275074019862680">when EMS needs to break its own rules</a> to care for a complex patient, and she suggested her own mnemonic – stop-ask-listen-evaluate (SALE) – for how to make “breaking protocol” one of the options in the protocol itself.</p>
<p>Another student related his father’s experience living with chronic illness. His condition frequently deteriorated because of delays in refilling medicine through his regular physician’s office. This student pointed to medical literature detailing how pharmacists can be given greater authority to refill medications for chronic diseases, preventing gaps in treatment, which would have saved his father significant hardship.</p>
<h2>Listening with both ears</h2>
<p>Down the road at Chatham University, I work with physician assistant students who are about to enter clinic for the first time. These students complete a workshop including many of the same communication exercises, including “listening with both ears”: listening not only to the patient, but also to what they themselves say to the patient, considering how it will be received. Students are encouraged to go home and practice until the words feel natural in their mouths, not scripted or mechanical – just like they drill anatomy facts and suturing skills.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Six young adults sit at a conference table, some of them in scrubs, as a doctor in a white coat leads a discussion." src="https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564312/original/file-20231207-17-53rp14.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"></a>
<figcaption>
<span class="caption">Part of a doctor’s responsibility is translating respect for patients into concrete techniques.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-teaching-nursing-students-royalty-free-image/1387152896?phrase=medical+student+clinic&searchscope=image%2Cfilm&adppopup=true">FatCamera/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>After their clinical year, the students return to reflect. Many of them report using patient-centered skills in challenging situations, such as validating patients’ concerns that had previously been dismissed.</p>
<p>Yet they also report a work culture where effective communication is often seen as taking too much time or as a low priority. Sixty years ago, Rabbi Abraham Joshua Heschel and psychiatrist William C. Menninger <a href="https://doi.org/10.1001/jama.1964.03070010087041">presented on The Patient as a Person</a> to the American Medical Association. Heschel declared that the profession was suffering from <a href="https://doi.org/10.1007/s11017-018-9472-x">a “spiritual malaria</a>,” his term for precisely the “high-tech, low-touch” attitude that my students encounter. The emphasis on technology and a rapid pace of treatment leaves scant room for caring, whether in Heschel’s day or ours.</p>
<p>In both programs where I teach, I aim to provide new practitioners with tangible skills that their future patients will experience as real “whole-person care” and not just a slogan on a commercial. Those patients will know that the people caring for them value all of them – their livelihoods, their life stories and the worlds they inhabit.</p><img src="https://counter.theconversation.com/content/212855/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Weinkle is affiliated with American College of Physicians and American Academy of Pediatrics.</span></em></p>The COVID-19 pandemic put a spotlight on how fragmented medical care can be. Relational, or person-centered, medicine is attempting to provide solutions.Jonathan Weinkle, Clinical Assistant Professor of Medicine and Part-Time Instructor of Religious Studies, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2172032023-12-14T13:48:45Z2023-12-14T13:48:45ZHow much could the NHS save if people had healthier lifestyles? Hundreds of millions according to research<figure><img src="https://images.theconversation.com/files/565332/original/file-20231212-19-rf91na.jpg?ixlib=rb-1.1.0&rect=77%2C132%2C5106%2C3292&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-backpack-hiking-on-footpath-autumn-2377721871">encierro/Shutterstock</a></span></figcaption></figure><p>The NHS spends a lot of time and money looking after people who smoke, or drink too much or don’t do enough exercise. Hospital admissions and treatments are an expensive business. </p>
<p>So what would happen if these people were able to change their lifestyles, for example by switching to vaping, moderating alcohol intake and being more physically active? My research suggests that costs to the NHS could be significantly reduced. </p>
<p>One of <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/bjhc.2023.0046">my studies</a> indicates that if half of England’s <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2022#smoking-prevalence-in-the-uk-by-sex-age-and-region">5 million smokers</a> switched to e-cigarettes or heated tobacco, the NHS would save more than £500 million a year. The shift away from cigarettes would lead to a decrease in cases of lung cancer, mouth cancer and heart disease. While the risks of vaping are still <a href="https://theconversation.com/how-bad-is-vaping-and-should-it-be-banned-197913">not entirely clear</a>, the damage caused by smoking has been firmly established.</p>
<p><a href="https://www.sciencedirect.com/science/article/abs/pii/S1090944323000613">Another study</a> I carried out in Italy reinforces this conclusion. It suggests that if half of Italy’s smoking population transitioned to alternative products, that country’s public health service could save over €700 million (£600 million) a year.</p>
<p>The larger figure comes from a slightly different cost structure for Italy’s health service, and the fact that more people smoke in Italy than in England. That study also delves into potential savings related to reducing excessive alcohol consumption and promoting increased physical activity.</p>
<p>My research <a href="http://dati.istat.it/Index.aspx?QueryId=16778&lang=en">used statistics</a> which suggest that just under 3% of Italians are currently considered heavy drinkers. Overindulging in alcohol can lead to many <a href="https://www.thelancet.com/pdfs/journals/lanrhe/PIIS2665-9913(23)00073-5.pdf">health problems</a>, including liver damage, heart defects, increased blood pressure, and a heightened risk of certain types of cancer.</p>
<p>I found that if a single heavy drinker (someone who consumes over four units of alcohol a day) out of every 1,000 Italians reduced their consumption to the recommended guidelines (two units a day for men, one a day for women), this would result in an annual saving to the health service of €60 million (£52 million). </p>
<p>Another finding was that if one physically inactive person out of every 100 Italians started to take the recommended level of at least 150 minutes of moderate physical activity, the gain would be €223 million (£193 million) per year. </p>
<p>Almost 40% of Italians do no exercise, which increases the risk of cardiovascular diseases, type 2 diabetes and obesity. It also <a href="https://www.who.int/news/item/04-04-2002-physical-inactivity-a-leading-cause-of-disease-and-disability-warns-who">elevates the risk</a> of colon cancer, high blood pressure, osteoporosis, depression and anxiety. </p>
<p>So overall, as the Italian government – in common with many wealthy countries – struggles with healthcare funding, close to €1 billion could be saved every year in direct costs if a relatively small number of people made fairly straightforward changes. </p>
<h2>Save lives, save money</h2>
<p>A similar impact could be had on the NHS (which has an annual budget of £182 billion) by targeting smokers, heavy drinkers and those who take no exercise. </p>
<p>The economic impact could in fact be far greater than my calculations suggest. For the savings predicted by my research do not account for the loss in productivity due to time off work connected to illness, treatment and recovery. </p>
<figure class="align-center ">
<img alt="Bottles of water held up in celebration." src="https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565334/original/file-20231212-19-lbgug.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">Contains no alcohol.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cheers-healthy-couple-cheering-fresh-water-1134634340">AePatt Journey/Shutterstock</a></span>
</figcaption>
</figure>
<p>Some may argue that given the risky nature of cigarettes and alcohol, a more straightforward – and economically beneficial – approach would be to implement an outright ban. After all, if successful, it could potentially result in even greater savings of lives and resources. </p>
<p>But banning people from doing things they like, even if those things are harmful, <a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">rarely works out well</a>. The idea of taking away the right to smoke or drink, or enforcing physical exercise would be a tough political sell. </p>
<p>Recognising that people are often inclined to engage in risky behaviour, the objective should be to reduce the excessive harm they cause themselves. A push towards encouraging and enabling people to smoke less, drink less and do more exercise would benefit them and significantly decrease the financial pressure on our healthcare systems.</p><img src="https://counter.theconversation.com/content/217203/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesco Moscone is affiliated with University of Ca' Foscari Venice </span></em></p>Small changes, big savings.Francesco Moscone, Professor of Business Economics, Ca' Foscari University of Venice, Brunel University LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2195042023-12-14T03:32:31Z2023-12-14T03:32:31ZWe followed 14 ‘long haulers’ for 3 months. Here’s what they told us about living with long COVID<figure><img src="https://images.theconversation.com/files/565680/original/file-20231214-29-kbdizh.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5875%2C3925&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-handsome-ill-sick-man-lying-2225051059">Yurii_Yarema/Shutterstock</a></span></figcaption></figure><p>At least <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00493-2/fulltext">65 million people</a> around the world are estimated to have <a href="https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition">long COVID</a>, which describes the continuation or development of symptoms at least three months after an initial COVID infection.</p>
<p>Long COVID is a complex, multi-system disease that can be disabling and may even <a href="https://time.com/6240713/long-covid-deaths/">be fatal</a> in some cases. We still don’t understand the exact causes of long COVID, and there’s no clear treatment for it.</p>
<p>Over three months, <a href="https://www.sciencedirect.com/science/article/pii/S0277953623008420">we followed 14 people</a> suffering from long COVID – or “long haulers” – to better understand their experiences. In particular, we wanted to see how their ability to manage their health (called agency) and the help they get from others (social support) influence how they fare.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-does-covid-become-long-covid-and-whats-happening-in-the-body-when-symptoms-persist-heres-what-weve-learnt-so-far-188976">When does COVID become long COVID? And what's happening in the body when symptoms persist? Here's what we've learnt so far</a>
</strong>
</em>
</p>
<hr>
<h2>A few key themes</h2>
<p>Participants recorded short videos about their daily lives, focusing on their symptoms, how they were coping, and any lifestyle changes they were making. </p>
<p>They experienced a range of symptoms, including fatigue, breathing difficulties and brain fog. Research has shown these are <a href="https://www.nature.com/articles/s41579-022-00846-2">common symptoms</a> among people with long COVID.</p>
<p>Participants faced psychological and social challenges, with some feeling lonely and hopeless, often made worse by social stigma around expressing mental distress. One participant said:</p>
<blockquote>
<p>Most of my family haven’t contacted me that much over the last five months. So I’ve really just been on my own 24/7, which does wear anyone down.</p>
</blockquote>
<p>Another said she had not</p>
<blockquote>
<p>reached out to my friends too much about it because I just feel like such a hypochondriac. </p>
</blockquote>
<figure class="align-center ">
<img alt="A senior woman sits on a couch looking out the window." src="https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565678/original/file-20231214-29-a9b1jz.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">People with long COVID may feel isolated.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/face-senior-caucasian-hoary-woman-looking-2264099993">Perfect Wave/Shutterstock</a></span>
</figcaption>
</figure>
<p>Some participants felt health-care professionals didn’t take their experiences and symptoms seriously or didn’t understand. One described “an overall very, very poor understanding of the pathophysiology of the condition which is harming patients like me”.</p>
<h2>Agency and social support</h2>
<p>Although each person had a unique experience with long COVID, we were able to group these experiences into clusters based on the social support they received and the agency they had in managing their condition. </p>
<p>Agency is a result of multiple factors that accumulate over time including socioeconomic background, education and health literacy. Agency can improve when people feel in control of their situation.</p>
<figure class="align-center ">
<img alt="A matrix divided into four quadrants representing the agency/social support clusters." src="https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564600/original/file-20231209-25-6mmwxy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We grouped participants into four clusters.</span>
<span class="attribution"><a class="source" href="https://www.sciencedirect.com/science/article/pii/S0277953623008420">Figueiredo et al., Social Science & Medicine, 2023</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In general, those with high agency and high social support reported a better experience managing long COVID than those in the other clusters. </p>
<p>People with agency sought out information about their condition and potential treatments, followed through with prescribed treatment plans when available, monitored symptoms, sought support, and were involved in advocacy and research.</p>
<p>Social support was similarly important, manifesting in different ways – for example a spouse who helped their partner get dressed, or a manager who supported reducing work days. In some cases friends provided regular support, while family played a crucial role, often becoming long-term informal carers.</p>
<p>Having a wide group of supporters helped long haulers feel like less of a burden to others and avoided the fear of over-relying on an individual carer. One participant’s church group provided a helpful social network, and reinforced her self-belief. Online communities also offered support.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-diagnosis-to-services-and-support-how-australias-long-covid-response-is-falling-short-215056">From diagnosis to services and support: how Australia's long COVID response is falling short</a>
</strong>
</em>
</p>
<hr>
<p>Those who had low agency and low social support generally reported the worst experiences. One participant who we grouped in this category said:</p>
<blockquote>
<p>Long COVID has destroyed so many aspects of my life […] it’s impossible to overstate the negative impact that it’s had.</p>
</blockquote>
<h2>Our findings align with existing evidence</h2>
<p>Our study was confined to a small group, and participants were only from Australia, which limits how much the findings can be generalised. </p>
<p>That said, our findings align with broader evidence highlighting the complexity of long COVID as a condition with <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00501-X/fulltext">both physical and psychosocial dimensions</a>.</p>
<p>Our study’s emphasis on patient agency and social support also corresponds with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850205/">emerging literature</a> emphasising the important role these factors play in chronic disease management.</p>
<figure class="align-center ">
<img alt="A woman comforts another woman." src="https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565679/original/file-20231214-27-iwujjf.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">Support from friends and family helps.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/shot-pretty-young-woman-supporting-comforting-2061681305">Josep Suria/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Supporting people with long COVID</h2>
<p>We suggest health-care professionals consider which “cluster” a person with long COVID falls into (low or high agency and low or high social support) and tailor the support they offer accordingly.</p>
<p>For example, long haulers who are more proactive (high agency) could benefit most from educational materials suggesting, for example, different ways to cope, safe exercise routines, diet tips, and strategies to manage mental health concerns.</p>
<p>Meanwhile, people with long COVID who find it hard to manage their health (low agency) but have good support from others (high social support), might benefit from educational materials that show their family and friends how to help them.</p>
<p>Being part of online communities could also help these patients. Although online groups can provide social support and improve a person’s sense of agency, not all information shared in these communities is accurate or reliable.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-physios-and-occupational-therapists-are-helping-long-covid-sufferers-195354">How physios and occupational therapists are helping long COVID sufferers</a>
</strong>
</em>
</p>
<hr>
<p>And what about people with low agency and low social support?</p>
<p>Providing clear, straightforward information about long COVID can enhance their participation in helping manage their health.</p>
<p>Connecting them with support groups, communities or counselling can improve social support. Evidence shows emotional connections <a href="https://bmjopen.bmj.com/content/13/3/e067166">help reduce feelings of distress</a> and boost wellbeing among people with long COVID.</p>
<p>Finally, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9648579/">case management services</a> can help long-haulers access and utilise community resources, and simplify their health-care journey.</p><img src="https://counter.theconversation.com/content/219504/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The project “EAT, MOVE, HEAL for Long-COVID” (Project ID: PRJ00000010) was funded by a 2022 Strategic Capability Deployment Fund, RMIT University, Victoria, Australia.</span></em></p><p class="fine-print"><em><span>Catherine Itsiopoulos has received funding from NHMRC for other research. She is a member of professional bodies including Dietitians Australia and The Australasian Society of Lifestyle Medicine. Catherine is a member of RMIT University 'Eat, Move Heal Network' researching to develop tools to support patients with long COVID19 at home.</span></em></p><p class="fine-print"><em><span>Jacob Sheahan receives funding from the Wellcome Trust, and the ACRC is funded by Legal and General.</span></em></p><p class="fine-print"><em><span>Zhen Zheng co-leads the Eat, Move, Heal for Long-COVID Program that aims to provide educational materials to people with long COVID and to health-care professionals. </span></em></p><p class="fine-print"><em><span>Magdalena Plebanski 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>Participants recorded short videos about their daily lives, focusing on their symptoms, how they were coping, and any lifestyle changes they were making.Bernardo Figueiredo, Associate Professor of Marketing, RMIT UniversityCatherine Itsiopoulos, Professor and Dean, School of Health and Biomedical Sciences, RMIT UniversityJacob Sheahan, Research Fellow, Edinburgh College of Art, The University of EdinburghMagdalena Plebanski, Professor of Immunology, RMIT UniversityZhen Zheng, Associate Professor, STEM | Health and Biomedical Sciences, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2180312023-11-28T00:50:29Z2023-11-28T00:50:29ZHow does Australia’s health system stack up internationally? Not bad, if you’re willing to wait for it<figure><img src="https://images.theconversation.com/files/561780/original/file-20231127-15-puo9t2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4831%2C2683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>When things are going bad in the health system, we are reassured we’ve got one of the best health systems in the world. But we’re rarely told where we actually stand relative to others.</p>
<p>A <a href="https://www.oecd.org/health/health-at-a-glance/">new report</a> from the Organisation for Economic Cooperation and Development (OECD) shows where Australia is doing relatively well – and not so well. The report is more than 200 pages with dozens of charts and tables. </p>
<p>Here we highlight five charts showing Australia’s relative performance. Overall, Australia’s health system performs well, but can come after long waits. And our use of antibiotics is trending in the wrong direction.</p>
<h2>1. We spend less than average but live longer than average</h2>
<p>Despite the rhetoric about the unsustainability of the health system, Australia performs well. When mapping health expenditure against life expectancy, Australia (marked by the red dot) sits in the best performing quadrant – and has done so for the past decade. </p>
<p><iframe id="tc-infographic-996" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/996/32f7548791bf05b7559d74976bfa0b955319adc5/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In contrast, the United States is stuck in the worst performing quadrant for the whole period – significantly higher spending than other countries with worse life expectancy. </p>
<p>The life expectancy measure is used here but it involves an implicit assumption that the principal impact on life expectancy is from the health system, which is not really the case. Nevertheless, it is a good measure of overall system performance and combined with spending provides a good measure.</p>
<h2>2. Most Australians rate their health as good or very good</h2>
<p>The vast majority of Australians (about 85%) rate their health as good or very good, with Australia performing better on this metric than most other similar countries. Often good health is conflated with good health care, and the data show that Australia also has more doctors per head than other countries.</p>
<p><iframe id="Ygo7Z" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Ygo7Z/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The founding charter of the World Health Organization (WHO) recognised that health is not just the absence of disease, but a “<a href="https://www.who.int/about/accountability/governance/constitution">state of complete physical, mental and social well-being</a>”. This points to a flaw in the nexus between good health and more health professionals. The WHO focus on well-being helps to explain why it is not surprising that, looking across countries, the number of doctors doesn’t appear to be a key determinant of performance on self-rated health.</p>
<h2>3. It’s harder to get a bed in aged care</h2>
<p>About 30% of people in OECD countries are over 65, while the Australian proportion is about 20%. The proportion of over-65s is rising everywhere. </p>
<p>A minority of older Australians (14%) use aged care, with most of these using home care. However, monitoring access to residential aged care (represented here by the number of long-term care beds per thousand population over 65) might act as a “canary in the coal mine”, highlighting where access problems exist.</p>
<p><iframe id="lBe4O" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/lBe4O/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In Australia, access to aged care beds is falling, by about 27% between 2011 and 2021. We started in the middle of the pack so this is a concern and probably contributes to more Australians being stuck in acute hospitals, rather than being in more appropriate accommodation in residential aged care. This “<a href="https://www.ama.com.au/articles/hospital-exit-block-symptom-sick-system">exit block</a>” in turn leads to problems of ambulance ramping.</p>
<h2>4. Australians wait too long for public hospital hip replacements</h2>
<p>Most publicly funded health systems are characterised by long waiting times for access to planned procedures such as hip replacements. Some waiting is to be expected as part of efficient management of operating theatre scheduling. But long waits, especially when the person is in pain, reflect poorly on management of the public hospital system.</p>
<p><iframe id="LNntD" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/LNntD/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The data shows that almost two-thirds of people waiting for hip replacement surgery in Australia waited more than three months. This is marginally worse than the OECD average. Unfortunately, our performance is deteriorating. </p>
<p>A number of states, such as <a href="https://www.health.vic.gov.au/planned-surgery-reform-blueprint">Victoria</a>, have developed strategies to improve the performance of the planned procedure system, or have identified opportunities for <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/about+sa+health/reporting+and+advisory+groups/health+performance+council/health+performance+council+reports">efficiency improvements in public hospitals</a> which would help address this issue. </p>
<p>Although it’s understandable that <a href="https://www.sciencedirect.com/science/article/pii/S2049080122011554">planned procedures were affected</a> by the first few years of the COVID pandemic, governments should have adapted their funding and provision systems to bring waiting times back to the pre-pandemic levels.</p>
<h2>5. Our use of antibiotics is going in the wrong direction</h2>
<p>Antibiotics have saved millions of lives. But public health experts have long recognised the emerging <a href="https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance">problem of antimicrobial resistance</a>, where inappropriate use of these drugs can lead to their reduced effectiveness over time. </p>
<p>Worldwide campaigns to promote appropriate use of antibiotics are bearing fruit and across the OECD, use of antibiotics is going down. </p>
<p>Unfortunately, Australia’s trend is in the reverse direction.</p>
<p><iframe id="AK4GO" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/AK4GO/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p><img src="https://counter.theconversation.com/content/218031/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett 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>How does Australia’s health care system compare to our peers in the OECD? Here we highlight five charts showing Australia’s relative performance.Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2181932023-11-22T17:05:16Z2023-11-22T17:05:16ZWhy NHS England is struggling – despite more staff and money<p><a href="https://www.kingsfund.org.uk/sites/default/files/2023-03/Public%20satisfaction%20with%20the%20NHS%20and%20social%20care%20in%202022_FINAL%20FOR%20WEB.pdf">Overall public satisfaction</a> with the NHS in England is currently at a 40-year low of 29%, a recent survey by the King’s Fund thinktank has found. People are not happy with waiting times for GP and hospital appointments. Over half of those surveyed think the service is beset by staff shortages. A similar percentage think the government does not spend enough money on the NHS. </p>
<p>This is despite the fact that in 2022-2023 the NHS received <a href="https://committees.parliament.uk/publications/41812/documents/207351/default/">£152.6 billion</a> in total budget – an increase (at 2022-2023 prices) of £28.4 billion compared to 2016-2017. The service has 32.4% more full-time staff too. Its workforce hit an all-time high of 1.275 million employees in February 2023 (up from from 963,000 in June 2013). </p>
<p>And yet, the figures around productivity show that people’s dissatisfaction is not without cause. Over the two years between 2019 and 2020 and 2020 and 2021, productivity across the NHS <a href="https://www.nao.org.uk/wp-content/uploads/2023/06/access-to-unplanned-or-urgent-care.pdf">decreased</a> by 23%. This extraordinary drop followed 14 years of productivity gains. </p>
<p>There are five primary reasons why the service is struggling to cope. These are: staff wellbeing, underfunded social care, an inadequate workforce plan, lack of access to emergency care and ongoing industrial action. </p>
<h2>Continuing burnout and work pressures</h2>
<p>In 2022, <a href="https://www.gmc-uk.org/-/media/documents/workforce-report-2023-full-report_pdf-103569478.pdf">23,838</a> doctors joined the profession but 11,319 left – an attrition rate 20% higher than in 2021, when 9,825 doctors left. The doctors’ union, <a href="https://www.bma.org.uk/news-and-opinion/burnout-hits-record-high">the BMA</a>, has highlighted concerns about doctors’ wellbeing. </p>
<p>In a survey of over 4,000 doctors in 2022, the General Medical Council <a href="https://www.gmc-uk.org/-/media/documents/somep-workplace-experiences-2023-full-report_pdf-101653283.pdf">found</a> that, in 2022, 50% of doctors were satisfied, down from 70% in 2021. More doctors reported working beyond their rostered hours on a weekly basis (70%, up from 59% in 2021). </p>
<p>Almost the same percentage said they are often unable to take breaks each week (68%, up from 49% in 2021). Many feel unable to cope with their workload each week (42%, up from 30% in 2021). One in four of the doctors surveyed were categorised as being at high risk of burnout in 2022, compared with 17% in 2021.</p>
<p>The Care Quality Commission, the independent regulator of health and adult social care in England, <a href="https://www.cqc.org.uk/sites/default/files/2023-10/20231030_stateofcare2223_print.pdf">recently highlighted</a> staff being overworked, exhausted and stressed – sometimes to the point of becoming ill, injured or leaving their job altogether.</p>
<h2>Continuing lack of access to adult social care</h2>
<p>Despite the UK government’s <a href="https://www.gov.uk/government/publications/people-at-the-heart-of-care-adult-social-care-reform-white-paper">stated</a> commitment to <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148559/next-steps-to-put-people-at-the-heart-of-care_a-plan-for-adult-social-care-system-reform-2023-to-2024-and-2024-to-2025.pdf">addressing</a> the long-term challenges facing the social care sector, the National Audit Office (NAO, the UK’s independent public spending watchdog) <a href="https://www.nao.org.uk/wp-content/uploads/2023/11/Report-reforming-adult-social-care-in-England.pdf">has painted</a> a bleak picture of the state of reforms. </p>
<p>In its latest report, entitled Reforming Adult Social Care
in England, the NAO highlights longs waiting lists (over 434,000 people waiting assessment or review by March 2023) and workforce shortages (over 150,000 vacancies in England). The report also notes pressures on local-authority finances, which are compounded by a lack of coherent planning to bring sustainable change. This lack <a href="https://theconversation.com/seven-ways-to-fix-the-broken-nhs-ambulance-services-207069">of continuity of care</a> is leading to unmet demands and delays in discharging patients. </p>
<h2>An inadequate workforce plan</h2>
<p>The UK government’s longterm workforce plan, <a href="https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf">published</a> in June 2023, was widely welcomed as the first comprehensive longterm strategy for the NHS workforce. However, as the General Medical Council pointed out, doubling the number of medical places from 2025 will only reap benefits <a href="https://www.gmc-uk.org/-/media/documents/workforce-report-2023-full-report_pdf-103569478.pdf">by 2030</a>, when these new cohorts complete their medical education. </p>
<p>The latest report of the cross-party <a href="https://committees.parliament.uk/publications/41812/documents/207351/default/">Public Accounts Committee</a> has criticised the plan’s lack of meaningful details and clarity on several areas of expenditure, including salaries, estates and infrastructure. Also, other than confirming £2.4 billion in funding to cover the costs of training in the first five years, it fails to promise sufficient funding in the medium and long-term. This risks putting NHS under untenable financial pressure. </p>
<p>Further, the plan proposes annual staff productivity gains of 1.5% to 2%, but does not detail <a href="https://committees.parliament.uk/publications/41812/documents/207351/default/">how this will be achieved</a>. It is similarly <a href="https://www.kingsfund.org.uk/blog/2023/10/enabling-workforce-plan-ambitions-focusing-recovery">weak</a> on retention measures, failing to address measures to retain staff, or to improve the culture and working environment that contributes to high attrition rates. </p>
<h2>Lack of access to urgent and emergency care</h2>
<p>Latest data from the NAO <a href="https://www.nao.org.uk/wp-content/uploads/2023/06/access-to-unplanned-or-urgent-care.pdf">reveals</a> that key targets for unplanned or urgent care are not being met. In March 2023, the proportions of A&E patients being admitted, transferred or discharged within four hours of arrival varied from 53.3% in the midlands to 62.1% in the south east against the target of 95%. </p>
<p>Ambulance average response times for category-1 incidents (life-threatening incidents) was eight minutes and 49 seconds in March 2023, against the average standard of seven minutes. Ambulance average performance for category-2 incidents (urgent but not life threatening) was over 39 minutes in March 2023, against the average standard of 18 minutes. </p>
<p>This reveals considerable variation in service performance and access, both between regions and between different providers.</p>
<p>I have long highlighted the challenges facing the emergency services. These include: <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08729-1#:%7E:text=In%20a%20recent%20study%2C%20Asghar,7%2C%2011%2C%2012%5D.">staff wellbeing</a>, performance being <a href="https://www.tandfonline.com/doi/abs/10.1080/14719037.2019.1642377">prioritised</a> over people, leaders <a href="https://www.tandfonline.com/doi/abs/10.1080/14719037.2017.1382278">deeming</a> response time targets to be the barometer of good organisational performance, <a href="https://theconversation.com/seven-ways-to-fix-the-broken-nhs-ambulance-services-207069">hospital handover delays</a> and the 999-call triage system. </p>
<h2>Continued industrial action</h2>
<p>The unprecedented situation of ongoing strikes by junior doctors and consultants, since September 2023, is proving damaging. NHS England <a href="https://www.england.nhs.uk/long-read/addressing-the-significant-financial-challenges-created-by-industrial-action-in-2023-24/">estimates</a> the financial costs of over 40 days of industrial action to be around £1 billion. </p>
<p>This has resulted in over <a href="https://www.nuffieldtrust.org.uk/news-item/how-are-strikes-by-health-care-staff-impacting-nhs-waiting-lists">880,000</a> operations and outpatient appointments being rescheduled. It has further seen <a href="https://www.health.org.uk/waiting-list">210,000</a> people added to already pressurised waiting lists. </p>
<p><a href="https://www.gov.uk/government/news/prime-minister-outlines-his-five-key-priorities-for-2023">Cutting down waiting lists</a> was one of the five pledeges Prime Minister Rishi Sunak announced in January 2023. Achieving that now seems <a href="https://www.theguardian.com/society/2023/oct/27/sunak-highly-unlikely-to-meet-promise-to-cut-nhs-waiting-lists-warn-health-leaders">highly unlikely</a>. </p>
<p>Despite the challenges it faces, public support for the core principles of the NHS remains overwhelmingly <a href="https://www.health.org.uk/sites/default/files/pdf/2023-11/NESTA_Foundational_Facts_9_Major_Challenges_Facing_Health_Final.pdf">strong</a>. Yet, repeated attempts by the government to reform and reorganise the service have failed to <a href="https://www.bmj.com/content/372/bmj.n248">“fix”</a> the problems it faces.
Recent evidence highlights significant <a href="https://bmjopen.bmj.com/content/13/2/e065993">challenges</a> regarding governance, accountability and decision-making arrangements within the NHS. </p>
<p>The NHS, like many other health systems, is still dealing with the effects of COVID-19 but the challenges it faces long predate the pandemic. Instead of more structural reforms, what the NHS <a href="https://www.health.org.uk/sites/default/files/pdf/2023-11/NESTA_Foundational_Facts_9_Major_Challenges_Facing_Health_Final.pdf">really needs</a> is support and the adequate, long-term, reliable funding required to address the toll a decade of austerity cuts has taken on the nation.</p><img src="https://counter.theconversation.com/content/218193/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paresh Wankhade is a Trustee at the Fire Service Research & Training Trust (FSRTT). </span></em></p>The NHS, like many other health systems, is still dealing with the effects of COVID-19 but the challenges it faces predate the pandemic.Paresh Wankhade, Professor of Leadership and Management, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2161892023-11-14T14:12:25Z2023-11-14T14:12:25ZHealth professionals need to collaborate. Changing how they’re taught helps build that skill<figure><img src="https://images.theconversation.com/files/557971/original/file-20231107-17-khqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's crucial that medical professionals learn to collaborate.</span> <span class="attribution"><span class="source">Katleho Seisa</span></span></figcaption></figure><p>When health professionals collaborate rather than operating in silos, everyone benefits – patients, families and the health system at large. This is a fact supported by ample <a href="https://www.mdpi.com/2227-9032/7/4/117">research</a> <a href="https://www.sciencedirect.com/science/article/abs/pii/S1939865416301175">evidence</a>. The professionals reap the benefits, too: staff satisfaction and retention are <a href="https://www.sciencedirect.com/science/article/abs/pii/S1939865416301175">improved</a> through collaboration.</p>
<p>But in the real world, health professionals and departments often slip into <a href="https://strategica-conference.ro/wp-content/uploads/2022/04/68.pdf">silo mentalities</a>. And silos in healthcare, as US cardiologist Laurence Sparling <a href="https://www.weforum.org/agenda/2020/11/healthcare-silos-are-bad-for-us-heres-the-cure/">writes</a>, are bad for healthcare. The “cure”, Sparling argues, is integrated healthcare with “cross-silo dialogue” – collaborative healthcare.</p>
<p>But collaboration is a skill that has to be taught. People don’t automatically know how to work in teams. Instead, they have to develop the competencies to do so. Where better to start than in the professional training they receive?</p>
<p>We are lecturers in the <a href="https://www.uwc.ac.za/study/all-areas-of-study/units/interprofessional-education-unit/overview">Interprofessional Education Unit</a> at the University of the Western Cape in South Africa. For two years, we tracked the development of students doing the first-year interprofessional theoretical module called Primary Health Care. </p>
<p>As we explain in <a href="https://pubmed.ncbi.nlm.nih.gov/36308973/">a recent paper</a>, we tweaked the material dimension (the physical and virtual spaces in which learning and teaching occurs) to help students develop some of the <a href="https://www.ipecollaborative.org/2021-2023-core-competencies-revision">core competencies needed for interprofessional work</a>. These include communication with patients, families, community members and health team members; as well as teamwork competencies with all their complexities and demands. </p>
<p>There were immediate and marked improvements in students’ results. We also saw that students became better at giving each other constructive feedback and working together when needed. These are important skills to harness as they work towards becoming health professionals.</p>
<h2>Changing things up</h2>
<p>Information is available to modern students with the flick of a finger on the screen. This means the curriculum needs to be constantly evaluated to develop an appropriate learning environment.</p>
<p>One model of education <a href="https://pubmed.ncbi.nlm.nih.gov/30870148/">shows</a> that learning environments in the health professions are made up of two parts. There’s the psychosocial dimension, itself made up of three components: the personal, social, and organisational. </p>
<p>The material dimension is the second part and was the major focus of our changes. Starting in 2019, we introduced a few substantial changes to the way we taught and evaluated students. (Not knowing, of course, that in 2020 these sorts of adaptations would become necessary in a pandemic.)</p>
<p>Firstly, we converted the course’s traditional classroom test into an online test. Secondly, we introduced changes to the blog in which students had to post responses to a lecture. Students had previously reported that the topics were too rigid and that they therefore simply regurgitated what lecturers had presented.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-professionals-work-in-teams-their-training-should-prepare-them-163586">Health professionals work in teams: their training should prepare them</a>
</strong>
</em>
</p>
<hr>
<p>Another change was to an assignment on how social issues are addressed by organisations in nearby communities. Usually, students had to visit those communities. But many had in the past expressed concern about the costs of travelling to communities – most relied on public transport – and their safety. They also struggled with the logistics of coordinating with team members from various departments. </p>
<p>So we instead invited community members into the classroom to share experiences and stories of their communities. Students were, of course, allowed and encouraged to pose questions to these community members. Students interacted with community members to gain insights into the local indigenous knowledge systems, which represent the unique knowledge passed down through generations within a society. This strengthened their use of polite language and clear communication in important interactions, both important for interprofessional communication.</p>
<h2>Marked improvements</h2>
<p>These innovations brought about immediate improvements in students’ results. At the end of 2019, following the changes from an in-classroom to an online test, the grade point average improved from 49.94% to 81.54%. While a more modest improvement, the average score for the blog went up by 4.53 percentage points. And finally, in the community assignment, the average grade point improved by nearly 12 percentage points.</p>
<p>A number of factors can be credited for these improvements. For instance, the use of <a href="https://books.google.co.za/books?hl=en&lr=&id=gVr0dVVLfeIC&oi=fnd&pg=PT7&dq=storytelling+as+a+learning+tool&ots=6Ql5_Qqpth&sig=35Y9FhA6NlOj1DyeW_WLxXGWLOk#v=onepage&q=storytelling%20as%20a%20learning%20tool&f=false">storytelling</a>, as in the meetings with community members, has long been thought to aid learning. </p>
<p>We received positive feedback from students. One said:</p>
<blockquote>
<p>(This) is a very interesting module because you get to meet other students doing different courses and learn more about their courses, our lecturer made it fun and interesting too.</p>
</blockquote>
<p>Another commented:</p>
<blockquote>
<p>The course was interesting and it showed how the inter-sectoral collaboration helps society and the health of many patients.</p>
</blockquote>
<h2>Applying our lessons</h2>
<p>Our advice to others lecturing in this field includes these points:</p>
<ul>
<li><p>Help students to get comfortable with online environments. Incorporate technology into the first-year curriculum. </p></li>
<li><p>To enhance teamwork, give students the chance to critically and productively confront and reflect on their perspectives from early on in a health professions education programme. </p></li>
</ul>
<p>Health professional educators must recognise the emergence of a new, digital paradigm in higher education. A comprehensive and integrated approach to education, research and community engagement is required as the healthcare industry transitions to an interprofessional model, pushing us to dismantle barriers and promote teamwork. Continually evaluating programmes to stay ahead of technological advancements helps prepare them for success.</p><img src="https://counter.theconversation.com/content/216189/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gérard Charl Filies works for UWC. </span></em></p><p class="fine-print"><em><span>Luzaan Africa works for UWC</span></em></p>It’s all too common for health professionals and departments to slip into silo mentalities.Gérard Charl Filies, Senior Lecturer: Interprofessional Education Unit, University of the Western CapeLuzaan Africa, Lecturer in the Interprofessional Education Unit , University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114412023-10-20T15:24:20Z2023-10-20T15:24:20Z‘We are worn out and no one cares’: why ambulance staff in UK and Australia are ready to quit the profession<p>The COVID-19 pandemic may be over, but its scars remain for those on the frontline of the health sector – not least in the ambulance services. And our research conducted separately in the <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2023.15.8.315">UK</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/09585192.2023.2237871">Australia</a> shows things are getting worse across the globe.</p>
<p>Ambulance staff in <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2022.14.1.6">many other</a> countries, including <a href="https://www.wsws.org/en/articles/2022/12/22/ambu-d22.html">Germany</a>, <a href="https://www.connexionfrance.com/article/French-news/Health/French-emergency-services-Why-it-is-now-harder-to-reach-15-number">France</a>, <a href="http://ijomeh.eu/Predictors-of-stress-among-emergency-medical-personnel-during-the-COVID-19-pandemic,128640,0,2.html">Poland</a>, <a href="https://www.tandfonline.com/doi/full/10.1080/07853890.2022.2137735">Spain</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10093884/">USA</a>, <a href="https://www.japantimes.co.jp/news/2022/08/16/national/japan-ambulances-struggle-covid/">Japan</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824029/">Israel</a> and <a href="https://www.deccanherald.com/india/too-little-too-late-emergency-services-require-urgent-care-1216452.html">India</a>, are also facing increased pressures. This is due to more people using ambulance services, more complex patient needs, not enough staff and resources, and unmanageable workloads. All these factors have made it difficult for many ambulance services to operate.</p>
<p>We studied two services similar in size and structure: the <a href="https://ambulance.nhs.wales">Welsh Ambulance Services NHS Trust</a> in the UK, and <a href="https://www.ambulance.vic.gov.au">Ambulance Victoria</a> in Australia. We found that both services are close to a point where they may not be able to meet the needs of the people they serve. And we identified similar issues and problems in both locations which are causing many employees to consider leaving the profession.</p>
<p>We found that nearly 45% of ambulance staff in Wales and 29% in Victoria are considering quitting. And in Victoria, 16% of ambulance services staff said they were looking to leave the profession within the next year, while 23% of participants in Wales said the same.</p>
<h2>Unmanageable workloads</h2>
<p>These are highly skilled healthcare professionals who are thinking about leaving their jobs for good. The main reason staff in both services gave us is unmanageable workloads, with many echoing the sentiments of one another.</p>
<blockquote>
<p>“The workload is huge and continues to grow. I regularly work 50 plus hours per week to keep on top of everything and still struggle.” (Wales)</p>
<p>“We are consistently given demands that are impossible to achieve. We are worn out and no one cares.” (Wales)</p>
<p>“I’m falling out of love with a job that I have loved and excelled at for nearly a decade and a half. Managers are pushing [targets] and budgets and times, while on road staff are exhausted.” (Victoria)</p>
<p>“Morale is the lowest I have ever seen in the ambulance service.” (Wales)</p>
<p>“Listening to the distressing phone calls I receive from road colleagues who are struggling … There is no respite of this pressure … I am hugely concerned for my frontline colleagues’ welfare.” (Wales)</p>
</blockquote>
<p>These comments feed into the issues of staff retention in both services as demands intensify. However, there is a perceived lack of understanding and support from management and more critically, a lack of resources. The real concern lies in how this will impact the quality of care provided to patients in both places.</p>
<p>Our findings are supported by other <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/paramedics-in-pandemics-protecting-the-mental-wellness-of-those-behind-enemy-lines/C0B1C08CF27CF1AD95EAC18B43D35E21">research</a> which indicates that ambulance services staff were the most likely to <a href="https://www.bbc.co.uk/news/uk-wales-60853142">say</a> their mental health had <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2022.14.1.6">deteriorated</a> following the COVID-19 pandemic, and by default, their ability to work effectively in the longer term.</p>
<p>Our research also shows that ambulance workers in Wales and Victoria, Australia are highly engaged and passionate about their work. They identify strongly with the job that they do. But they are approaching a crisis point due to increasing workload, burnout and low morale.</p>
<figure class="align-center ">
<img alt="A yellow ambulance driving down a road." src="https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554539/original/file-20231018-21-7y65hl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Welsh Ambulance NHS trust ambulance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cardiff-wales-april-2021-aerial-view-1952101864">Ceri Breeze/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Potential solutions</h2>
<p>The problems we found in our studies can be solved by ambulance management on either side of the globe. The most important thing is to provide more resources to support and retain this highly skilled workforce, which could help to reduce burnout and keep staff in this essential job.</p>
<p>Ambulance services must prioritise improving staff wellbeing, and efforts to do so should be inclusive, employee-led and proactive. Creating a stable and sustainable workforce could help in responding to changes in service and health needs. All levels of management should be given the appropriate training too. Taking these approaches could ensure that the work of ambulance services staff and other healthcare professionals is properly valued.</p>
<p>We hope that the findings from our studies will be used to create new ways to improve the workplace culture in Wales and Victoria. We also welcome other healthcare organisation using our findings to protect and support the wellbeing of their staff.</p><img src="https://counter.theconversation.com/content/211441/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research on both sides of the globe shows that unmanageable workloads is the main reason why many ambulance service staff are considering quitting the profession.Julian Hunt, Research Officer School of Health and Social Care, Swansea UniversityJohn Gammon, Deputy Head (Innovation and Engagement) of the School of Health and Social Care, Swansea UniversityPeter Holland, Professor in Human Resource Management and Employee Relations, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2141932023-10-06T12:30:23Z2023-10-06T12:30:23ZHealth on the ballot as Argentina poised to elect ‘anarcho-capitalist’ bent on slashing social protections<figure><img src="https://images.theconversation.com/files/551487/original/file-20231002-25-wdcz31.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C3384%2C2228&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hand that wields the chain saw looks set to carry the crown.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/presidential-candidate-javier-milei-of-la-libertad-avanza-news-photo/1701087602?adppopup=true">Tomas Cuesta/Getty Images</a></span></figcaption></figure><p>The front-runner heading into <a href="https://www.as-coa.org/articles/poll-tracker-argentinas-2023-presidential-election">Argentina’s presidential vote on Oct. 22</a> is prone to wielding a chain saw – both physically and metaphorically.</p>
<p><a href="https://www.economist.com/the-americas/2023/09/07/meet-javier-milei-the-frontrunner-to-be-argentinas-next-president">Javier Milei</a>, a right-wing libertarian whose brash demagoguery has <a href="https://www.washingtonpost.com/world/2023/08/16/javier-milei-donald-trump-argentina/">drawn comparisons to Donald Trump</a> and <a href="https://worldcrunch.com/world-affairs/javier-milei-bolsonaro">Brazil’s former President Jair Bolsonaro</a>, likes to <a href="https://www.cnn.com/2023/10/01/americas/chainsaw-candidate-argentina-javier-milei-hnk-intl/index.html">brandish the power tool at campaign events</a> as a symbol of what he intends to do if elected: cut back on government.</p>
<p>Milei has promised to take his chain saw to the ministries of <a href="https://cnnespanol.cnn.com/2023/08/30/milei-ministerios-eliminar-por-que-de-que-se-encargan-orix-arg/">education, environment and women’s rights</a>, to name but a few, and to <a href="https://english.elpais.com/international/2023-08-18/far-right-candidate-javier-milei-launches-attack-on-argentinas-scientific-community.html">ax funding for scientific research</a>. The country’s central bank would also <a href="https://www.economist.com/by-invitation/2023/09/29/javier-milei-argues-that-argentinas-central-bank-should-not-exist">cease to exist</a>, if Milei fulfills his <a href="https://www.americasquarterly.org/article/mileis-path-to-dollarization-riddled-with-doubts/">pledge to “dollarize</a>” Argentina’s economy – that is, to scrap the country’s peso and replace it with the U.S. currency.</p>
<p>Milei promises a radical change to Argentina’s current trajectory. And his <a href="https://www.msn.com/en-us/news/world/far-right-candidate-javier-milei-launches-attack-on-argentinas-scientific-community/ar-AA1frQ9N">attacks on science and education</a> form part of a troubling <a href="https://www.dissentmagazine.org/article/is-anti-intellectualism-ever-good-for-democracy/">anti-intellectual, right-wing populism</a> that threatens liberal democracies worldwide.</p>
<p>However, as an <a href="https://www.macalester.edu/geography/facultystaff/ericcarter/">expert on the history of public health in Argentina</a>, I believe Milei could face stiff resistance if he tries to undo a long-standing consensus on the need for the government to provide universal health care and other social services.</p>
<h2>A shock to the political system</h2>
<p>A <a href="https://www.weforum.org/people/javier-gerardo-milei">former economics professor</a>, Milei is a relative political newcomer, having served just one term in the national congress. As with other right-wing populists, he casts himself as a political outsider.</p>
<p>When it comes to public spending, Milei <a href="https://english.elpais.com/international/2023-08-14/javier-milei-the-ultra-right-libertarian-and-anarcho-capitalist-who-represents-angry-argentina.html">styles himself as an “anarcho-capitalist</a>.” His plans include eliminating both the Ministry of Health and <a href="https://www.conicet.gov.ar/?lan=en">Conicet</a>, the agency that funds most academic research in Argentina, and folding them into a new <a href="https://www.pagina12.com.ar/582281-como-se-hace-el-ajuste-que-propone-milei">Ministry of Human Capital</a>, with a fraction of their current budget and personnel. </p>
<p>Milei’s rhetoric taps into a <a href="https://www.statista.com/statistics/1367447/public-opinion-president-alberto-fernandez-argetina/">deep well of discontent</a> among Argentinians with the current government led by Alberto Fernandez, a member of the <a href="https://www.oxfordreference.com/display/10.1093/oi/authority.20110803100318435">Peronist party</a>, which has held power for most of the past three decades. </p>
<p>Since assuming power in 2019, Fernandez has presided over <a href="https://www.reuters.com/markets/argentine-shoppers-face-daily-race-deals-inflation-soars-above-100-2023-09-13/">runaway inflation</a>, <a href="https://apnews.com/article/argentina-poverty-inflation-massa-milei-d515d077f61147b203149d9e2a6a164c#">rising poverty</a> and <a href="https://apnews.com/article/caribbean-buenos-aires-argentina-3aa151384f591b367865dd8faa418007">accusations of official corruption</a>.</p>
<p>The government’s handling of the COVID-19 pandemic saw an <a href="https://www.scielo.br/j/hcsm/a/YpyrzqkvHZBVBhVTYzjxsHc/?lang=en">initial boost in public support for Fernandez</a>. But by the middle of 2021, frustration with the government was starting to boil over – due in part to <a href="https://www.aljazeera.com/news/2021/2/20/argentina-health-chief-asked-to-resign-after-vip-vaccine-access#:%7E:text=The%20government%20has%20been%20rocked,getting%20vaccinations%20before%20their%20turn.">accusations of preferential priority</a> for COVID-19 vaccinations for Peronist officials and their friends and families. </p>
<p>Meanwhile, for Milei, the pandemic proved to be a <a href="https://foreignpolicy.com/2023/08/23/milei-argentina-presidential-election-politics-economy-villarruel/">catalyst for his rise to political fame</a>. Fanning the flames of public discontent, he appeared frequently on television and in social media to call out a “political caste” for imposing what he deemed unnecessary and economically damaging pandemic restrictions. His popularity <a href="https://elpais.com/argentina/2023-08-20/jovenes-hartos-de-los-politicos-y-sin-futuro-la-tierra-fertil-en-la-que-enraizo-milei.html">has since skyrocketed among young people in Argentina</a>, attuned to “anti-progressive” messaging online and exhausted by economic crisis and political corruption. Milei <a href="https://www.iprofesional.com/politica/389621-quienes-son-los-votantes-de-javier-milei">polls much better among men</a>, in part because many women are alarmed by <a href="https://www.nbcnews.com/news/latino/thousands-women-march-latin-america-abortion-rights-rcna118147">his intention to reverse the country’s 2021 legalization of abortion</a>.</p>
<h2>Health as a social right</h2>
<p>Evidently, Milei has tapped into a <a href="https://www.aljazeera.com/news/2023/8/15/argentina-primary-results-reflect-frustrations-desire-for-change-experts">thirst for sweeping political change</a>. </p>
<p>But there is reason to believe that his proposals to reduce the government’s role in the health sector would run into strong headwinds, given the longer-term pattern in Argentina and across the Latin America region.</p>
<p>Today, there is a <a href="https://www.statista.com/statistics/914586/general-opinion-healthcare-system-argentina/#statisticContainer">broad public acceptance</a> of a strong role for government in guaranteeing and protecting the right to health care, along with other “social rights” like education and gender equality.</p>
<p>As I explain in my new book, “<a href="https://uncpress.org/book/9781469674452/in-pursuit-of-health-equity/">In Pursuit of Health Equity</a>,” a hemispheric “social medicine” movement has, over the past century, played a key role in the construction of welfare state institutions in many Latin American countries. Led by progressive doctors, left-wing academics and health activists, social medicine – which sees health as being intrinsically tied to socio-economic factors – has sought to build robust health systems as part of a <a href="https://social.desa.un.org/sites/default/files/migrated/22/2021/04/Argentina_SP-Governance.pdf">strong social safety net</a>. Social medicine advocates see health as a right rather than a commodity.</p>
<p>In Argentina, <a href="https://www.aljazeera.com/news/2023/6/20/a-divided-legacy-marks-50-years-since-perons-return-to-argentina">Juan Domingo Perón</a>, the founder of the populist Peronist movement that Milei now hopes to dislodge from power, understood social medicine. To make Argentina’s population healthier and more productive, in the 1940s Perón expanded the government’s role in health care while advancing policies to <a href="http://www.columbia.edu/%7Elnp3/mydocs/state_and_revolution/Juan_Peron.htm">improve labor conditions, nutrition and housing</a></p>
<figure class="align-center ">
<img alt="A crowd of people stand around a large figure with 'PERON' written at the top." src="https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=478&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=478&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=478&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=601&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=601&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552379/original/file-20231005-27-on4kok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=601&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A huge 1948 rally in support of Juan Peron.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/buenos-aires-argentina-shown-is-the-tremendous-throng-news-photo/514876518?adppopup=true">Bettmann/Getty Images</a></span>
</figcaption>
</figure>
<p>Later, politically active academics took on prominent roles in health planning in the leftist governments of Brazil, Argentina and Bolivia in the late 1990s and early 2000s, <a href="https://uncpress.org/book/9781469674452/in-pursuit-of-health-equity/">opposing market-based reforms and the incursion</a> of a U.S. health care model that critics say puts profit over people.</p>
<h2>Healthy approval ratings</h2>
<p>Milei’s popularity suggests another swing in the pendulum of Latin American politics, which has tended to oscillate between state-centered and free-market-oriented models.</p>
<p>Clearly, a large contingent of Argentine voters agree with his basic contention that the current government has provoked an <a href="https://foreignpolicy.com/2022/08/15/argentina-imf-debt-massa-fernandez/">economic crisis</a> with <a href="https://brownpoliticalreview.org/2023/03/peso-problem-argentinas-economic-crisis/">overly generous spending</a>.</p>
<p>Yet his more extreme proposals are likely to meet resistance. </p>
<p>As Argentinian scholar <a href="https://scholar.google.es/citations?user=6lMifj8AAAAJ&hl=es">Maria Laura Cordero</a> and I found in <a href="https://doi.org/10.1016/j.healthplace.2022.102870">our survey during the pandemic</a>, Argentinians have mostly positive feelings toward public health institutions and the people who work in them, coupled with intense disdain for the political class. Around 67% of those we surveyed approved of the performance of the health sector, compared with 22% approval of political leadership during the pandemic.</p>
<p>Dismantling the public health sector in favor of market mechanisms like a <a href="https://infonews.com/javier-milei-la-libertad-avanza-elecciones-presidenciales-sistema-de-salud-educacion-recorte.html">voucher system to pay for health care</a> or <a href="https://enys.conicet.gov.ar/la-salud-publica-en-guardia/">putting public hospitals in competition with one another</a>, as Milei has suggested, may prove to be unpopular. </p>
<p>There is broad consensus about a fundamental right to health care in Argentina, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9973504/">as elsewhere in Latin America</a>. And the public, by and large, understands that government intervention is necessary to make health care accessible to the poor and to respond to public health emergencies like the recent pandemic.</p>
<p>Health workers, deeply invested in the precepts of social medicine, are sure to resist Milei’s attempts at health reform. In response to Milei’s plans, the president of the Argentine Public Health Association stated that “<a href="https://enys.conicet.gov.ar/la-salud-publica-en-guardia/">solidarity and the building of the common good are present in the DNA</a>” of health personnel in Argentina. The public is also likely to worry at the prospect of increased fees and the lack of coverage for basic health care needs.</p>
<h2>Research under attack</h2>
<p>Milei hasn’t won anything yet, nor is there a clear rightward tilt in Latin American politics – in the past two years, leftist presidential candidates have prevailed in countries as varied as Brazil, Chile, Colombia and Guatemala. But even if he fails to push through his radical agenda, the rhetoric of his campaign could serve to undermine confidence in Argentina’s health and science institutions.</p>
<p>Milei capitalizes on the politics of resentment, <a href="https://www.revistahcsm.coc.fiocruz.br/english/la-ciencia-en-argentina-y-sus-demonios">vilifying “unproductive” researchers who receive support from Conicet</a>, especially social science and humanities scholars.</p>
<p>Such attacks on government support for scientific research, health care and education are consistent with a global right-wing ideology, typified by the likes of Viktor Orban of Hungary or <a href="https://floridapolitics.com/archives/618813-gov-ron-desantis-vetoes-14-5-million-in-health-care-spending/">Ron DeSantis</a>, a Republican presidential candidate in the U.S.</p>
<p>Within the bottom-line mentality of neoliberalism – a political ideology that preaches free-market reforms over state involvement – such research is seldom viewed as profitable, nor does it tend to offer the possibility of new therapies or technologies produced by “hard” sciences and modern biomedicine. </p>
<p>But as the history of Latin American social medicine shows, social scientists can counter that, with time, their approach has helped build more just, free and healthy societies. And that legacy is now at stake as Argentinians head toward the polls.</p><img src="https://counter.theconversation.com/content/214193/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric D. Carter does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Argentinians will vote in a new president on Oct. 22, 2023. But the front-runner’s plans to slash health funding might find resistance.Eric D. Carter, Professor of Geography and Global Health, Macalester CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1965052023-10-03T14:08:50Z2023-10-03T14:08:50ZDiscrimination is the biggest career obstacle for women of colour in the NHS – new research<figure><img src="https://images.theconversation.com/files/525092/original/file-20230509-27-vjlzax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/surgical-team-performing-surgery-modern-operation-1932229913">Photoroyalty/Shutterstock</a></span></figcaption></figure><p>In March 2023, NHS midwife <a href="https://www.bmj.com/content/380/bmj.p534">Olukemi Akinmeji</a> won an employment tribunal case against the hospital in Kent where, as an employee, she had faced race discrimination and victimisation. </p>
<p>That same month, <a href="https://www.nursingtimes.net/news/policies-and-guidance/nurses-racial-discrimination-ruling-will-drive-change-vows-nhs-england-07-03-2023/">Michelle Cox</a>, a healthcare manager and senior nurse, won a case against NHS England and NHS Improvement Commissioning in Manchester. She too had faced racial discrimination. </p>
<p>These cases follow the legal action launched in August 2022 by marketing executive <a href="https://www.thetimes.co.uk/article/nhs-whistleblower-recorded-her-bosses-racist-chat-5sjmldxqt">Melissa Thermidor</a> against the NHS Blood and Transplant service. She provided recordings of conversations between staff members that backed up her claims that she had been subjected to racism.</p>
<p>According to <a href="https://www.england.nhs.uk/wp-content/uploads/2022/04/Workforce-Race-Equality-Standard-report-2021-.pdf">NHS data from 2021</a>, black and minority ethnic women are the most likely of all NHS staff groups to experience discrimination from patients or colleagues. The harms they experience due to <a href="https://read.dukeupress.edu/meridians/article-abstract/8/2/166/138446/Double-JeopardyTo-Be-Black-and-Female?redirectedFrom=fulltext">sexism</a> in the workplace are compounded by their ethnicity. </p>
<p>My doctoral research looks at the obstacles black and minority ethnic women face in the NHS in terms of career development. In the chapter I recently contributed to the <a href="https://www.e-elgar.com/shop/gbp/research-handbook-on-leadership-in-healthcare-9781800886247.html">Research Handbook on Leadership in Healthcare</a> (edited by Naomi Chambers), I show how systemic discrimination is the single biggest impediment to these women being able to advance in their jobs. </p>
<h2>The barriers to career progression</h2>
<p>There is a notable lack of research on the workplace experiences of black and minority ethnic women leaders in healthcare. In 2021 I carried out a literature review to address this. </p>
<p>I identified eight barriers or drivers (often two sides of the same coin) to career progression for this group. These are: systemic discrimination; leadership and organisational cultures; recruitment and talent management; policies; training; monitoring and accountability; work-life balance; and support.</p>
<p>Systemic discrimination, the most pervasive impediment, refers to discrimination embedded in institutional policies, practices or processes, as opposed to the actions of individual people.</p>
<p>Research has long shown systemic discrimination at work in the NHS. In 2016, minority ethnic NHS staff were <a href="https://www.hsj.co.uk/workforce/minority-ethnic-candidate-chances-of-recruitment-in-nhs-fall-back-finds-nhse/7029577.article">1.56 times more likely</a> to enter formal disciplinary processes than white staff. More recently, a 2022 report by the Fawcett Society and the Runnymede Trust charities <a href="https://www.fawcettsociety.org.uk/Handlers/Download.ashx?IDMF=72040c36-8cd6-4ae3-93f3-e2ad63a4b4b0">found</a> that women of colour are more likely (27%) to have been described as aggressive compared to white women (17%).</p>
<p>A <a href="https://bmjopen.bmj.com/content/bmjopen/13/4/e069846.full.pdf">study</a>, published in April 2023 looked at a large sample (37,971) of people applying for specialist NHS training posts (medical and surgical) between 2021 and 2022. It found that applicants from most of the ethnic minority groups were less successful than their white British counterparts. It pointed to recruitment policies and processes as key factors driving this inequality.</p>
<p>In addition to the racism and sexism often experienced by ethnic minority women more broadly, black women, in particular, also have to contend with anti-blackness. </p>
<p>In 2010, the black feminist scholar Moya Bailey and the writer who goes by the name Trudy coined the term “<a href="https://www.researchgate.net/publication/323736560_On_misogynoir_citation_erasure_and_plagiarism">misogynoir</a>” – anti-black misogyny – to describe this compounded discrimination. It amounts, as the US legal scholar Kimberlé Crenshaw <a href="https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=1052&context=uclf">put it</a> in a landmark paper in 1989, to a form of erasure – being fundamentally overlooked by society. </p>
<p><a href="https://www.mckinsey.com/featured-insights/diversity-and-inclusion/women-in-the-workplace">Recent research</a> shows that little has changed. Black women are subject to a wider range of microaggressions in the workplace. They are often the only black woman in any given setting. And they are three times more likely than their peers to think regularly about leaving their jobs. </p>
<figure class="align-center ">
<img alt="A graphic showing racial discrimination against ethnic minority women in healthcare leadership positions." src="https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504416/original/file-20230113-20-iy3bue.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Barriers and drivers of career progression for black and minority ethnic women leaders in UK healthcare.</span>
<span class="attribution"><span class="source">Rakhi Chand</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<h2>How discrimination is compounded</h2>
<p>In the UK, this compounded discrimination is further exacerbated by, among other things, being a migrant or having a non-standard British accent. <a href="https://www.researchgate.net/publication/340784255_The_Workplace_Experiences_of_BAME_Professional_Women_Understanding_Experiences_at_the_Intersection">Accent discrimination</a> can lead to employees receiving poorer pay, having limited access to professional networks, or fewer chances of promotion. Here too, it can see people <a href="https://www.researchgate.net/publication/297894255_Investigation_of_nurses'_intention_to_leave_a_study_of_a_sample_of_UK_nurses">more likely</a> to leave their jobs. </p>
<p>This often has a negative impact on an employee’s <a href="https://psycnet.apa.org/record/1943-03751-001">mental wellbeing</a> and <a href="https://www.maryseacoletrust.org.uk/wp-content/uploads/2019/02/Race-Equality-in-the-Workplace-for-publication-Feb-19.pdf">physical health</a> too. The long-term physical problems it can lead to include increased blood pressure and heart rates, higher levels of the primary stress hormone cortisol, and unhealthy behaviours such as drinking alcohol or smoking. </p>
<p>Line managers are uniquely placed to influence an employee’s emotional attachment to an organisation. <a href="https://www.researchgate.net/publication/297894255_Investigation_of_nurses'_intention_to_leave_a_study_of_a_sample_of_UK_nurses">Research</a> shows that their support – including for training and advancement opportunities – can be pivotal in decisions to leave or, conversely to stay in a role or even the organisation. </p>
<p>However, research has long noted the lack of diversity in healthcare leadership. A <a href="https://www.england.nhs.uk/wp-content/uploads/2014/10/equality-analysis-wres-april-16.pdf">2014 report</a> on equality in the NHS workforce found that black and minority ethnic executives were “entirely” absent, and women “disproportionately” absent, from the boards of all key NHS national bodies in 2013. </p>
<p>To remedy this situation, academics and practitioners alike have repeatedly called for better reporting on gender data, broken down by ethnicity, within healthcare management. </p>
<p>Yet, until the publication of the Workforce Race Equality Standard report in 2022, this appears to not have happened within the NHS. Not having access to such data is a problem. <a href="https://www.england.nhs.uk/wp-content/uploads/2014/08/edc7-0514.pdf">Research</a> has long shown that when a healthcare workforce does not reflect the population it serves, patients’ health outcomes worsen as a result. </p>
<p>The fact that black and minority ethnic women are under-represented at leadership levels is, of course, <a href="https://www.tuc.org.uk/research-analysis/reports/bme-women-and-work">not unique</a> to the healthcare sphere. It is also <a href="https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/6be731ea72/Workforce-Survey-Report-2019.pdf">not exclusively a UK problem</a>. </p>
<p>Anyone wanting to improve diversity and inclusion within their workforce must engage with the obstacles that black and ethnic minority women face. Addressing inequality benefits everyone.</p><img src="https://counter.theconversation.com/content/196505/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rakhi Chand 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>When hospital and GP staff do not reflect the population they serve, patients’ health suffers.Rakhi Chand, Doctoral Researcher, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2091722023-09-13T13:30:46Z2023-09-13T13:30:46ZHow Tripadvisor for hospitals and clinics can improve healthcare<figure><img src="https://images.theconversation.com/files/539231/original/file-20230725-23-9ysyqh.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C4577%2C3044&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-medical-suit-shows-her-hand-2191837701">africa pink/Shutterstock</a></span></figcaption></figure><p>Online reviews and ratings provided by the likes of Tripadvisor and Yelp have changed how people select their hotels, restaurants, flights, plumbers and hair salons. Even hospitals and health clinics have got in on the act, with websites such as Care Opinion, Doctify and Google Opinion. </p>
<p>But healthcare is different from other sectors. The way patients write comments can have an effect beyond just helping other patients choose a doctor. We’ve <a href="https://www.sciencedirect.com/science/article/pii/S0166497222001729">found evidence</a> it can lead to better healthcare. </p>
<p>This optimistic view that patients’ comments could lead to better healthcare is not an idea shared by everyone. In 2008, the launch of the patient review website iWantGreatCare in the UK caused upset among healthcare professionals. </p>
<p>Some doctors <a href="https://www.theguardian.com/society/2008/jul/13/nhs.health">claimed</a> that allowing patients to rate and review every medic who has treated them will expose these healthcare workers to abuse, libel and even personal attack. </p>
<p>There was a similar reaction elsewhere in the world. Healthcare professionals raised concerns about the accuracy and reliability of online reviews. How can patients without a medical background evaluate the doctors and the relevance of their decision? </p>
<p>Also, there are concerns about the potential for biased or malicious reviews that could unfairly tarnish a professional’s reputation. There is an entire industry devoted to <a href="https://www.theguardian.com/money/2023/apr/22/it-can-be-incredibly-profitable-the-secret-world-of-fake-online-reviews">selling fake reviews</a> – which could be positive or negative.</p>
<p>And, finally, the evaluation of the comments on patient review websites is mostly focused on what could be referred to as “extra care”. The comments and ratings on almost all of these websites are about the facilities, such as the parking, delays or even doctors’ or receptionists’ attitudes, and not about the care or treatment.</p>
<p>Facing these criticisms, patient online comments are often underused – or just plain ignored. For example, Le Point, a French newspaper, published for the first time <a href="https://www.dailynewsen.com/breaking/doctors-awards-le-point-responds-to-h114138.html">a ranking of 1,000 doctors</a>, but their ranking is based only on academic publications and does not include patients’ online posts. </p>
<p>In the UK in 2014, the first published <a href="https://www.gov.uk/government/publications/nhs-hospitals-complaints-system-review">report by NHS on patient complaints</a> raised the issue that these online complaints were a “toxic cocktail”. Some health practitioners still use the term to refer to these review websites.</p>
<p>Since patient review websites are still an evolving phenomenon, there are many questions about whether these comments can be beneficial for the healthcare industry and how. </p>
<figure class="align-center ">
<img alt="Doctor's receptionist and patient" src="https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545274/original/file-20230829-21-hnqhyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Comments on these websites often focus on things such as the receptionist’s attitude rather than actual healthcare.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/receptionist-doctors-office-greets-patient-49056157">Lisa F. Young/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Value in the comments</h2>
<p>Drawn to these intriguing questions, our recent study, published in the journal <a href="https://www.sciencedirect.com/science/article/pii/S0166497222001729">Technovation</a>, found that patient reviews can be used by hospitals to identify where to act (by localising the department or service addressed with the most negative comments), and on what to act (what theme provides satisfaction and so should be kept, or causes dissatisfaction and needs to be improved?). They can also be used to find new ways to improve the service. </p>
<p>Our findings are based on an analysis of 134 negative reviews that a French hospital (anonymized in the study) received on an online rating platform. We applied a qualitative research method to analyse the reviews and found areas of improvement. </p>
<p>As a result, we observed that the hospital’s overall rating on the platform raised from 3.05 (out of 5.00) to 4.47 after consultants recommended improvements based on the comments.</p>
<p>So the value of patient comments is not just in the number of stars given but in the comment posted. These comments, when included in the three ideas above, can be used by hospitals to rethink how patients are cared for. </p>
<p>There are two implications of this result. First, thanks to having these posts publicly available online, a hospital can use feedback, not just from its own patients but from those of other hospitals, to improve its practices. So a patient’s comment can have a much wider impact than the poster intended. </p>
<p>Second, through the written comments left on a patient-feedback website, patients can take an active role in improving healthcare – but only if their comment is constructive and not merely vengeful.</p>
<p>The emerging patient review platforms, therefore, go beyond just being the Tripadvisors of healthcare. They could be used to improve the experience of patients, help hospitals and clinics to improve the quality of care, and gain better results in national healthcare evaluations, which is often essential for securing state budgets – at least in most European countries.</p>
<p>Patient review platforms could shake up healthcare delivery by helping doctors, clinics and hospitals spot weak points and provide better services when resources are increasingly overstretched.</p><img src="https://counter.theconversation.com/content/209172/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mohammad Saleh Farazi received funding from the European Horizon 2020 project DiHECO (grant number 952012). He was previously affiliated with the University of Montpellier.</span></em></p><p class="fine-print"><em><span>Bez Sea receives funding from the european project H2020 DiHECO (grant number 952012)</span></em></p><p class="fine-print"><em><span>This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 952012.</span></em></p>Patient online comments are often underused, if they are used at all.Mohammad Saleh Farazi, Senior Lecturer in Innovation and Enterprise, London South Bank UniversityBez Sea, Associate Professor, Université de MontpellierIrene Georgescu, Full Professor, Université de MontpellierLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2077532023-08-22T14:52:07Z2023-08-22T14:52:07ZSix pregnancy terms you probably won’t hear again, including ‘high risk’ and ‘failed’<figure><img src="https://images.theconversation.com/files/542983/original/file-20230816-17-towf59.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5152%2C3435&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The language midwives use is an important part of the care they provide.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-pregnant-woman-visit-gynecologist-doctor-1404770729">Blue Planet Studio/Shutterstock</a></span></figcaption></figure><p>Medical terminology evolves alongside our understanding of medicine. As time goes by, new terms are adopted while others are abandoned. In midwifery, there should always be a strong emphasis on the language we use, particularly in pregnancy.</p>
<p>In 2020, the Royal College of Midwives launched an initiative to discover the impact language has on women. The aim of the <a href="https://www.rcm.org.uk/rebirth-hub/">Re:Birth</a> project was to find language around pregnancy that could be understood both by people delivering maternity care and those receiving it. </p>
<p>It was the first project of its kind to consult the maternity community (including new mothers and healthcare professionals) directly on their preferred language to describe labour and birth. The findings of the project supported the fact that many women were less concerned about the way their baby was born but with whether they had a positive experience and felt safe and listened to.</p>
<p>Last year, the Royal College of Midwives published a <a href="https://www.rcm.org.uk/media/6234/re_birth_summary_.pdf">report</a> outlining their findings and a new pocket guide is being issued to midwives this year. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?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"></span>
</figcaption>
</figure>
<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/spain-is-the-egg-donation-capital-of-europe-heres-what-its-like-to-be-a-donor-205780">Spain is the egg donation capital of Europe – here’s what it’s like to be a donor</a></em></p>
<p><em><a href="https://theconversation.com/dirty-red-how-periods-have-been-stigmatised-through-history-to-the-modern-day-206967">‘Dirty red’: how periods have been stigmatised through history to the modern day</a></em></p>
<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
<hr>
<p>Here are six maternity terms you are now unlikely to hear:</p>
<h2>1. Delivery</h2>
<p>The term “birth” has now been accepted, rather than the term “delivery”, which has commonly been used in the past. Women and health professionals also wanted accurate, specific descriptions as far as possible to describe what had happened in the labour and birth. For example, “birth with forceps” or “birth with ventouse”. This also includes “caesarean birth”.</p>
<h2>2. Low risk / high risk</h2>
<p>“Universal care needs” is being used rather than “low risk”. While “additional care needs” is now the preferred term for “high risk”. The word “risk” is associated with uncertainty and it is vital that women feel comfortable and confident during their pregnancy.</p>
<h2>3. Normal</h2>
<p>“Normal birth” is a term that has long been used by midwives and other healthcare professionals to describe a spontaneous, physiological vaginal delivery. But what counts as “normal”? Does this label someone as “abnormal” if they did not experience what we classify as “normal” birth?</p>
<p>The new preferred term, “spontaneous vaginal birth”, covers spontaneous labour without significant medical interventions such as induction and oxytocin. It also covers spontaneous vaginal birth without the need for instruments, such as forceps. </p>
<h2>4. Emergency caesarean</h2>
<p>The new overarching term for an operative caesarean section is “caesarean birth”. This replaces the word “emergency”, which is a term that may cause alarm. The term “unplanned caesarean birth” is now preferred over “emergency caesarean”. </p>
<h2>5. Incompetent cervix</h2>
<p>“Incompetent cervix” has connotations of personal failure. So, the preferred term is now “cervical insufficiency”. </p>
<h2>6. Failure / failed</h2>
<p>During the Re:Birth project, women were keen to share how terms such as “failure to progress” can contribute to feelings of failure and trauma. “Delayed progress in labour” or “slow labour” are now preferred terms.</p>
<p>We can apply the same logic to terms such as “failed induction” or “failed homebirth”. “Induction of labour, with delay and followed by operative birth” and “transfer in during planned homebirth” are favoured, respectively. </p>
<figure class="align-center ">
<img alt="A pregnant woman wearing a yellow top clutches her belly." src="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.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">Language matters.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-african-american-woman-doing-morning-1842709132">Prostock-studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>Language which infantalises pregnant women, such as “good girl” or “you are allowed/not allowed to” should also be avoided, as should language which has connotations of blame. Examples of this include “poor maternal effort” and “refused”. </p>
<p>During pregnancy and birth, which is a vulnerable time for many, the role of the midwife is to empower women and to value their autonomy over their care decisions. </p>
<p>The Nursing and Midwifery Council’s <a href="https://www.nmc.org.uk/globalassets/sitedocuments/standards/standards-of-proficiency-for-midwives.pdf">standards of proficiency for midwives</a> document states that midwives provide universal care for all women and new-born infants. Midwives support physical, psychological, social, cultural and spiritual safety. The emphasis on psychological care is clear, therefore, with language having a profound impact on wellbeing.</p>
<p>Healthcare professionals must acknowledge that the language we use is an important part of the care we provide. Improved psychological safety and wellbeing is closely linked to improved safety, positive outcomes and future experiences. Language matters.</p><img src="https://counter.theconversation.com/content/207753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Aubrey 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>Several familiar maternity terms have been abandoned after a consultation with pregnant women and healthcare professionals.Sarah Aubrey, Lead Midwife for Education, University of South WalesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2099252023-08-21T13:01:08Z2023-08-21T13:01:08ZThe order in which you acquire diseases could affect your life expectancy – new research<figure><img src="https://images.theconversation.com/files/542634/original/file-20230814-15-6ly3wb.jpg?ixlib=rb-1.1.0&rect=47%2C0%2C5310%2C3497&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Almost two-thirds of UK adults aged 65 and over possess two or more long-term health conditions.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-couple-tourists-sea-resort-1596444508">EvgL/Shutterstock</a></span></figcaption></figure><p><a href="https://doi.org/10.1016/S0140-6736(12)60240-2">More than 25%</a> of adults in the UK have two or more long-term health conditions. This increases to 65% for people older than 65 years, and to almost 82% for those aged 85 or older. </p>
<p><a href="https://doi.org/10.1016/S2468-2667(23)00098-1">Our study</a> assessed how a number of multiple long-term health conditions (<a href="https://www.nhs.uk/mental-health/conditions/psychosis/overview/">psychosis</a>, diabetes and congestive heart failure) develop over time, and what effect this can have on life expectancy. We chose these conditions because, together, they can lead to substantial reductions in how long someone lives.</p>
<p>We analysed the development of these conditions over a 20-year period for more than 1.6 million adults aged 25 and over. We used data held within the <a href="https://saildatabank.com/">SAIL databank</a>, which provides secure access to routinely collected anonymous health and administrative records for the population of Wales.</p>
<p>We also worked with patients and the public from across the UK to understand their experience of living with multiple long-term conditions. </p>
<p>Using statistical models, we examined the order and timing of developing psychosis, diabetes and congestive heart failure in patients of the same age, sex and area-level deprivation – and the related impact on their life expectancy. </p>
<h2>The impact of disease order</h2>
<p>We found that the order in which people developed these diseases had an important impact on their life expectancy. People who developed diabetes, psychosis and congestive heart failure, in that order, had the largest loss in life expectancy (approximately 13 years, on average).</p>
<p>People who developed the same conditions in a different order were less affected. So, for example, a 50-year-old man in an area of average deprivation could experience a difference in his life expectancy of more than 10 years, depending on the order in which he developed the three diseases. </p>
<p>Our research also identified that people who first developed diabetes, then psychosis and finally congestive heart failure carried a higher risk of developing the next long-term health condition, or dying within five years of their last diagnosis. </p>
<p>However, the development of further conditions is not always life-limiting. For example, people diagnosed with psychosis and diabetes – in any order – had a higher life expectancy than those diagnosed with psychosis alone. While this was a surprising finding, we expect people with diabetes to have more regular contact with health professionals through diabetic clinics, for example, which may improve their overall health. </p>
<p>Our study also found that congestive heart failure on its own, and in combination with psychosis (in any order), had a similar effect on life expectancy to the “worst case” combination of diabetes, psychosis and congestive heart failure (in that order). </p>
<figure class="align-center ">
<img alt="An empty bed in a hospital surrounded with medical equipment" src="https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542796/original/file-20230815-25-8wyoa2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The application of this research could lead to improved outcomes for the NHS.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/national-health-service-uk-19th-march-608498993">Imran Khan's Photography/Shutterstock</a></span>
</figcaption>
</figure>
<p>This is the first study to examine how the order of developing multiple long-term conditions affects a person’s life expectancy. This research could be used to inform patients, healthcare providers and decision-makers on the appropriate identification of diseases and management of patient care. In turn, this could lead to improved outcomes for patients and the NHS. </p>
<p>Our research also helps to support healthcare delivery by looking at the factors that may increase a person’s risk of developing disease, as well as identifying potential opportunities for disease screening and earlier intervention.</p>
<h2>Applying our research</h2>
<p>Future research could evaluate the impact of screening programmes and interventions in delaying the development of further long-term conditions and extending life.</p>
<p>However, it is important to note that our research used information from routinely collected health records, which are not always accurate – some diagnoses may be missing or delayed. Also, diagnoses are not always accurately described. These are all important factors in being able to accurately estimate the impact of multiple long-term conditions on life expectancy. </p>
<p><a href="https://phenotypes.healthdatagateway.org/">Further research funded by Health Data Research UK</a>, the national institute for health data science, aims to harmonise how this data is collected and reported. Over time, this will improve the quality of information obtained from routinely collected health records for research. </p>
<p>While our study examined the development of one group of multiple long-term conditions, this approach could be replicated for any other combination of conditions – including the development of long-term health conditions following COVID-19 infection (known as long COVID), and the impact this has on quality of life.</p>
<p>Those living with multiple long-term conditions often experience increased use of healthcare services and medications, as well as greater difficulty with day-to-day tasks. This leads to a reduced quality of life as well as reduced life expectancy. </p>
<p>Our research has shown that the combination of long-term conditions and order in which you develop them may both have a substantial impact on your life expectancy. However, this relationship can be complex, and the development of further disease does not always reduce life expectancy.</p><img src="https://counter.theconversation.com/content/209925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rhiannon Owen receives funding from the Academy of Medical Sciences (AMS), Health and Care Research Wales (HCRW), Heath Data Research UK (HDRUK), Medical Research Council (MRC), and the National Institute for Health and Care Research (NIHR). She is affiliated with the National Institute for Health and Care Excellence (NICE). </span></em></p>People who developed diabetes, psychosis and congestive heart failure, in that order, experienced the largest reduction in life expectancyRhiannon Owen, Professor of Statistics, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2105922023-08-16T15:14:18Z2023-08-16T15:14:18ZNigerian women ensure they get the best possible healthcare by managing unequal power relations with men<figure><img src="https://images.theconversation.com/files/541539/original/file-20230807-31794-nxav4q.jpg?ixlib=rb-1.1.0&rect=9%2C0%2C6221%2C4147&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rural women in Nigeria negotiate healthcare decisions with their partners. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cameroonian-refugee-couple-that-ran-away-with-dozens-of-news-photo/1239282860?adppopup=true">Kola Sulaimon/AFP via Getty Images</a></span></figcaption></figure><p>Nigeria is a patriarchal society. Authority is vested in men, who tend to exert power and control over women in various spheres of life. This has an impact on women’s health and decisions about their healthcare.</p>
<p>Women’s health is affected not only by medical conditions and childbearing, but also by cultural behaviour and traditions. Social factors such as gendered access to healthcare or employment also affect people’s capacity to lead healthy lives. </p>
<p>The Nigerian feminist scholar Obioma Nnaemeka has described feminism in an African context as a matter of <a href="https://doi.org/10.1086/378553">negotiation</a> and compromise. She calls it “negofeminism”. It involves “give and take” instead of confrontational exchanges. </p>
<p>This concept helped me, as a <a href="https://www.researchgate.net/profile/Ogochukwu-Udenigwe">global health researcher</a>, to understand what rural Nigerian women said about seeking healthcare during and after pregnancy. </p>
<p>For our <a href="https://doi.org/10.1186/s12978-023-01647-3">study</a>, my colleagues and I interviewed women and their spouses in two rural communities in southern Nigeria. </p>
<p>Our findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism’s concepts of alliance, community and connectedness were highlighted through men’s constructive involvement in maternal health.</p>
<p>We found women were not passive victims. Instead, they navigated patriarchal environments to yield the best possible maternal health outcomes by gaining control of their healthcare decisions.</p>
<p>Recognising this form of agency can help in formulating policies and programmes that acknowledge how women’s wider social environments influence their health. </p>
<h2>Maternal health in Nigeria</h2>
<p>In Nigeria, limited access to quality healthcare contributes to <a href="https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf#page=411">556 pregnancy-related deaths per 100,000 live births.</a>. UNICEF reports that Nigeria contributes <a href="https://www.unicef.org/nigeria/situation-women-and-children-nigeria">10% of the global pregnancy-related death burden</a>.</p>
<p>Some scholars have argued that women are only able to seek healthcare if they <a href="https://doi.org/10.1177/0162243917736139">can make independent decisions</a>. But this approach often ignores <a href="http://dx.doi.org/10.1136/bmjgh-2020-003808">women’s realities</a>, such as the fact that their social network (mothers, grandmothers, spouses and community members) influences their use of healthcare services. </p>
<p>Nevertheless, as <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">our study</a> shows, social dimensions don’t necessarily impede women’s autonomy.</p>
<p>Therefore, I believe that discussions of maternal health in an African context need to consider women’s experiences of being “African” and “women”. </p>
<h2>The study</h2>
<p>We <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-023-01647-3">studied</a> two predominantly rural communities in Esan South-East and Etsako West, local government areas of Edo State in southern Nigeria. We conducted five women-only focus group discussions with a total of 39 women, and three men-only focus group discussions with 25 men. Participants were chosen from a database of women participating in maternal health interventions.</p>
<p>We asked them who women first consulted for pregnancy care, and who made the decisions about seeking maternal healthcare. We also asked about their experiences of men’s involvement in maternal and child health.</p>
<p>We categorised their responses as negotiation, collaboration and manoeuvring. </p>
<p>It appeared that men were considered the decision-makers at the household level. Participants said a woman’s spouse should be the first to know of her pregnancy. Both men and women said men should make all the decisions about healthcare during pregnancy, even though it was clear that women sometimes influenced decisions.</p>
<p>Describing her experience, one woman said: </p>
<blockquote>
<p>In the aspect of care, I will tell my husband, so he will decide. After my husband knows, I will go to the hospital to tell the doctor so he can tell me what to do. </p>
</blockquote>
<p>Similarly, men noted that women “cannot just go to healthcare facilities without the husband’s decision”. </p>
<p>But they also made comments like:</p>
<blockquote>
<p>My wife will tell me, ‘take me to go and see the nurse’. When I am not around, she can go see the doctor on her own. It is a normal thing in our community.</p>
</blockquote>
<p>Both men and women said it was important to get skilled care, especially for complications.</p>
<p>The act of the women telling the men can be thought of as a form of negotiation by women to influence decisions on access to maternal healthcare. First, she recognises the patriarchal environment and assigns the decision-making authority to men. But she is also using her agency in that environment.</p>
<p>Notions of men’s responsibility and collective action on maternal health were evident in the study. In these communities, men’s duties as expectant fathers were mainly of financial support to cover costs associated with pregnancy, including clinic visits, cost of delivery, essential medicines and feeding. </p>
<p>It can be argued that in ascribing decision-making authority to men, women benefit from men’s duty and responsibility to be providers. Women said they could not afford the high cost of maternal healthcare on their own. There was “give and take”.</p>
<p>Some women showed their resistance to men’s involvement in their pregnancy. They reported secretly seeking maternal healthcare without informing their partners. In this they were indicating control over their lives. </p>
<h2>Why this matters</h2>
<p>Our findings show that it’s important to involve women’s communities and spouses in maternal health programmes. </p>
<p>We show that patriarchy affords men power over decision-making or financial resources. Women are not passive in these situations, they actively find ways around it to ensure they have access to skilled healthcare during pregnancy.</p>
<p>This study shows that maternal health is not always an individual responsibility – it can be one for the woman’s community and the nation. Ignoring this can undermine programmes and policies aimed at improving women’s health.</p><img src="https://counter.theconversation.com/content/210592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ogochukwu Udenigwe 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>Rural women in Nigeria circumvent patriarchy to make decisions on their healthcare.Ogochukwu Udenigwe, Doctoral Candidate, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2089862023-08-07T11:07:17Z2023-08-07T11:07:17ZLinking police and healthcare data could help better identify domestic abuse – new research<figure><img src="https://images.theconversation.com/files/538035/original/file-20230718-19-w6ftpx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4608%2C3428&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Healthcare professionals can play a vital role in identifying and helping people who are experiencing domestic abuse.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stop-violence-against-womensexual-abuse-human-1465291778">HTWE/Shutterstock</a></span></figcaption></figure><p>Identifying domestic abuse victims earlier could help to reduce future emergency medical admissions. <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00126-3/fulltext">Our new research</a> shows how this could be done before a victim even involves the police by connecting information gathered by the police and hospitals.</p>
<p>Our study showed that many victims of domestic abuse often visit accident and emergency departments before the police get involved. This means that healthcare professionals can play a crucial role in identifying and helping people who are experiencing abuse.</p>
<p>We combined data from the police with data from GPs and accident and emergency hospital admissions. We focused on residents in the South Wales Police catchment area who had experienced domestic abuse between August 2015 and March 2020, and who were given a public protection notification (PPN). This is a document that records safeguarding concerns about adults or children.</p>
<p>Connecting this data with health information gives a wide view of how domestic abuse affects people’s health. Health records are kept in a secure database called the Secure Anonymised Information Linkage (SAIL) Databank. </p>
<p>This provides access to different kinds of information, such as records from doctors’ visits, hospital stays, accident and emergency visits, and death records. All data in the databank is anonymous, ensuring that individuals cannot be identified.</p>
<p>Using mathematical models, we then identified the factors that increased the risk of negative outcomes, such as hospital and A&E admissions or death within 12 months of the PPN.</p>
<h2>What we found</h2>
<p>Of the 8,709 people who experienced domestic abuse, 71.8% were women. Within a year of experiencing abuse, 3,544 of the victims had negative outcomes, such as an A&E admission, while there were 48 deaths.</p>
<p>We also found that certain factors increased the likelihood of negative outcomes. These included being younger, having multiple incidents of abuse, getting injured during the abuse, being assessed as high-risk, being referred to other agencies, having a history of violence, experiencing attempted strangulation, or being pregnant.</p>
<p>Pregnant victims, in particular, faced more risks, which affected their own health and the health of their babies. Certain factors like smoking, obstetric issues and taking specific medications (like antidepressants and antibiotics) increased the risk of having a negative outcome after experiencing domestic abuse.</p>
<p>By studying different patterns, we could predict how severe the cases of domestic abuse were in terms of risk. For example, victims who had frequent interactions with the police were at higher risk.</p>
<p>However, victims who had conflicts related to child contact had a lower risk of experiencing negative outcomes. This is because the perpetrator might not be living with the victim. </p>
<h2>What are the implications?</h2>
<p>Our findings show the importance of considering a victim’s health history in identifying domestic abuse. Identifying certain patterns could lead to earlier interventions.</p>
<p>It is crucial for different organisations to work together and share information to identify and help vulnerable individuals effectively. Identifying specific risk factors, like being younger or having a history of violence, could help identify victims more effectively. This would include investigating previous visits to the hospital, conducting thorough assessments for pregnant victims who are at high risk and connecting different pieces of information.</p>
<p>These measures could help prevent further victimisation and ensure that people receive the right support and resources.</p>
<p>Our research highlights the importance of healthcare settings, especially emergency departments, in identifying and addressing domestic abuse. Training programmes could help emergency department staff identify potential cases of domestic abuse, even if the victim does not explicitly disclose the abuse. </p>
<p>By connecting different sources of information and identifying people at high risk, health professionals could take necessary actions and refer victims to support services.</p>
<p>Our study looked at situations where abuse was officially reported, so victims who did not report it were not included. </p>
<p>We did not include cases where women went to the emergency room for obstetric reasons either. This means that the impact of domestic abuse during pregnancy may be underestimated in our findings.</p>
<p>In future, further research should be undertaken to validate the findings of this study in different settings and populations. It would also be helpful to look at information from other sources, such as social services and housing records, to get a better picture of the factors that contribute to domestic abuse and its consequences.</p>
<h2>Protecting privacy</h2>
<p>While linking data from different organisations can be helpful for research, it is also important to protect people’s privacy. If we want to link data at a national level for purposes other than research, we would need a public consultation on what data is shared and to discuss how people’s privacy would be protected. </p>
<p>This is important because if people were afraid that their data would be shared with the police, they might not seek help from emergency services. When victims can be encouraged to talk, however, this study underlines the importance of training A&E staff to recognise and address potential cases of abuse.</p><img src="https://counter.theconversation.com/content/208986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasha Kennedy wishes to thank Benjamin Rowe from South Wales Police for his input.
This research was funded by the National Institute for Health Research, Public Health Research Board (reference number NIHR133680: Unlocking Data to Inform Public Health Policy and Practice).
The study was also supported by Health Care Research Wales through the National Centre for Population Health and Wellbeing Research, supported by ESRC through Administrative Data Research Wales, and received infrastructure support through Health Data Research UK.
This study makes use of anonymised data held in the SAIL databank. We would like to acknowledge all the data providers who make anonymised data available for research.</span></em></p><p class="fine-print"><em><span>Amrita Bandyopadhyay wishes to thank Benjamin Rowe from South Wales Police for his input.
This research was funded by the National Institute for Health Research, Public Health Research Board (reference number NIHR133680: Unlocking Data to Inform Public Health Policy and Practice).
The study was also supported by Health Care Research Wales through the National Centre for Population Health and Wellbeing Research, supported by ESRC through Administrative Data Research Wales, and received infrastructure support through Health Data Research UK.
This study makes use of anonymised data held in the SAIL databank. We would like to acknowledge all the data providers who make anonymised data available for research.</span></em></p>New research linking police and healthcare data shows that victims of domestic abuse are detectable before the involvement of the police.Natasha Kennedy, Senior research officer and data scientist, Swansea UniversityAmrita Bandyopadhyay, Research Officer and Data Scientist at the National Centre for Population Health and Wellbeing Research, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2091802023-08-02T17:13:54Z2023-08-02T17:13:54ZHow swarming animals can help humans and AI make better decisions<figure><img src="https://images.theconversation.com/files/535929/original/file-20230705-23-hte9mu.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C6381%2C3444&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Starling murmurations form as daylight fades over their roosting sites. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-large-flock-starlings-birds-fly-1930366580">Shutterstock / Albert Beukhof</a></span></figcaption></figure><p>The word swarm often carries negative connotations – think biblical plagues of locusts or high streets full of last-minute shoppers during the Christmas rush. However, swarming is essential for the survival of many animal collectives. And now research into swarming has the potential to change things for humans too.</p>
<p>Bees swarm to make their <a href="https://academic.oup.com/aesa/article/97/1/111/11469">search for new colonies</a> more effective. Flocks of starlings use <a href="https://link.springer.com/article/10.1007/s00265-018-2609-0">dazzling murmurations to evade and confuse predators</a>. These are just two examples from nature but swarming can be seen in almost every corner of the animal kingdom. </p>
<p>Research from mathematicians, biologists and social scientists is helping us understand swarming and harness its power. It’s already being used for <a href="https://ieeexplore.ieee.org/abstract/document/4424900">crowd control</a>, <a href="https://ieeexplore.ieee.org/abstract/document/5366981">traffic management</a> and to understand the <a href="https://ts2.space/en/swarm-intelligence-for-public-health-and-epidemiology/">spread of infectious diseases</a>. More recently, it’s starting to shape how we use data for healthcare, operate drones in military conflicts and has been used to beat near-insurmountable betting odds in sporting events.</p>
<p>A swarm is a system that is greater than the sum of its parts. Just as many neurons form a brain capable of thought, memory and emotion, groups of animals can act in unison to form a “super brain”, displaying highly complex behaviour not seen in individual animals. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/V4f_1_r80RY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>Artificial life expert Craig Reynolds revolutionised the study of swarming in 1986 with the publication of the <a href="https://dl.acm.org/doi/10.1145/37401.37406">Boids model</a> computer simulation. The Boids model breaks down swarming into a simple set of rules. </p>
<p>The Boids (bird-oids) in the simulation, like avatars or characters in a video game, are instructed to move in the same direction as their neighbours, move towards the average position of their neighbours, and avoid collisions with other boids. </p>
<p>Boids simulations are strikingly accurate when compared with real swarms. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_5tJ8jwd64Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>The Boids model suggests that swarming does not need leaders to coordinate behaviour – like pedestrians in a town centre rather than a guided museum tour. The complex behaviour we see in swarms arises from interactions between individuals following the same simple rules in parallel. In the language of physics, this phenomenon is known as <a href="https://www.sciencedirect.com/science/article/pii/S1476945X07000049?casa_token=6Lr13Hi0yzUAAAAA:eN6wloN9IBvWw5zl_iqVp1lFgyiKGa1P17Uk9QYkVLj6f0-DsFBQ1iFB0MT_YYKSNSi7S2mr">emergence</a>. </p>
<h2>The hive mind</h2>
<p>In 2016, US technology company <a href="https://unanimous.ai/">Unanimous AI</a> used the power of swarm intelligence to <a href="https://unanimous.ai/unu-superfecta-11k/">win the Kentucky Derby “superfecta” bet</a>, successfully predicting the first, second, third and fourth-placed riders in the famous US horse race. </p>
<p><a href="https://www.sbnation.com/2016/5/5/11594904/2016-kentucky-derby-picks-predictions-nyquist-mor-spirit">Industry experts</a> and <a href="https://hothardware.com/news/bing-predicts-kentucky-derby-winner-social-algorithms">conventional machine learning algorithms</a> made swathes of incorrect predictions. However, amateur racing enthusiasts recruited by Unanimous AI pooled their knowledge to beat the <a href="https://bleacherreport.com/articles/2638613-kentucky-derby-results-2016-winner-payouts-highlights-and-order-of-finish">541/1 odds</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537381/original/file-20230713-14892-fn0yq9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hopeful punters bet millions of dollars on the Kentucky Derby each year.</span>
<span class="attribution"><span class="source">Shutterstock / Cheryl Ann Quigley</span></span>
</figcaption>
</figure>
<p>The volunteers’ success lay in the way in which their predictions were generated. Instead of voting on riders and aggregating their choices, the volunteers used <a href="https://unanimous.ai/swarm/">Unanimous AI’s swarm intelligence platform</a> to participate in a real-time digital tug of war, inspired by swarms of birds and bees.</p>
<p>All volunteers simultaneously pulled a dial towards their respective choices. This allowed people to change their preferences in response to the actions of others (for example, a person may have switched to pulling towards their second choice, B, rather than their first choice, C, if they saw A and B were the clear favourites). </p>
<p>Responding to one another in real time allowed Unanimous AI’s volunteers to collectively outperform <a href="https://www.sbnation.com/2016/5/5/11594904/2016-kentucky-derby-picks-predictions-nyquist-mor-spirit">highly-informed individuals</a>. </p>
<p>What’s more, had the most frequent individual picks of the volunteers determined the ordering, only the <a href="https://www.npr.org/sections/thetwo-way/2016/05/07/477171967/nyquist-wins-the-2016-kentucky-derby#:%7E:text=Carr%2FGetty%20Images-,Nyquist%2C%20ridden%20by%20Mario%20Gutierrez%2C%20crosses%20the%20finish%20line%20during,Churchill%20Downs%20on%20May%207.&text=Nearly%20one%20year%20since%20American,his%20own%20at%20Churchill%20Downs.">2016 winner</a> and <a href="https://www.sbnation.com/2016/5/7/11616138/2016-kentucky-derby-odds-post-nyquist-my-man-sam-exaggerator-bet-how">bookies’ favourite</a>, <a href="https://www.racingpost.com/profile/horse/896792/nyquist">Nyquist</a>, would have been placed correctly. </p>
<h2>Health concerns</h2>
<p>Similar swarming technologies are also of increasing interest in the <a href="https://www.nature.com/articles/s41586-021-03583-3">healthcare</a> sector, where <a href="https://www.frontiersin.org/articles/10.3389/fsoc.2022.1038854/full">talk of an AI revolution</a> is prompting <a href="https://digitalcommons.law.scu.edu/chtlj/vol36/iss4/2/">increasing concerns around patient privacy</a>. </p>
<p>As the reliance on <a href="https://link.springer.com/content/pdf/10.1007/s11518-019-5437-5.pdf">data-driven techniques in healthcare</a> increases, so too does the demand for extensive patient datasets. One way to meet these demands is to <a href="https://jamanetwork.com/journals/jama/fullarticle/2768851">pool information between institutions and in some cases, countries</a>. </p>
<p>However, the transfer of patient data is often subject to <a href="https://www.jmir.org/2017/2/e47/">stringent data protection regulations</a>. A solution to this problem is to use only in-house data, though this often comes at the expense of diagnostic accuracy. </p>
<p>An alternative lies in swarming. Researchers believe swarm intelligence can <a href="https://healthcare-in-europe.com/en/news/ai-with-swarm-intelligence-to-analyse-medical-data.html">preserve diagnostic accuracy</a> without the need for raw data exchange between institutions. </p>
<p><a href="https://www.nature.com/articles/s41586-021-03583-3">Preliminary studies</a> have shown decentralising data storage into a network of interacting nodes can give institutions the benefit of shared wisdom. This means there isn’t a central hub coordinating the flow of information, and institutions can’t access the private patient data of each other. </p>
<p>Centralised machine learning uses data uploaded to a shared hub where machine learning takes place using all available data. In decentralised systems, each institution separately stores its data in its own node. The machine learning happens locally at each node (using only in-house data), but the results of machine learning are shared between the network, to the benefit of all nodes. This process ensures that raw patient data is not exchanged between institutions, preserving patient privacy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537570/original/file-20230714-29-ahjkkr.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"></a>
<figcaption>
<span class="caption">Swarms of drones may soon populate the battlefield.</span>
<span class="attribution"><span class="source">Shutterstock / Andy Dean Photography</span></span>
</figcaption>
</figure>
<h2>Swarms and warfare</h2>
<p>Drone technology is increasingly used in front-line combat, in recent times most notably by <a href="https://edition.cnn.com/2023/06/03/europe/ukraine-secretive-drone-program-russia-war-intl/index.html">Ukrainian forces</a> in the <a href="https://www.cfr.org/global-conflict-tracker/conflict/conflict-ukraine">ongoing Russia-Ukraine conflict</a>. However, as it stands, conventional drone technology requires <a href="https://www.airuniversity.af.edu/Portals/10/ASOR/Journals/Volume-1_Number-4/Lowther.pdf">one-to-one supervision</a>. </p>
<p><a href="https://www.army.mod.uk/news-and-events/news/2022/09/british-army-carries-out-successful-swarming-drone-capability/">Current defence research</a> aims to facilitate communication between drones, allowing one controller to operate swarms of drones. The development of such technology promises to vastly improve the <a href="https://www.military.africa/2023/06/drone-swarm-technology-an-overview/">scalability</a>, <a href="https://cdnsciencepub.com/doi/10.1139/juvs-2018-0009">reconnaissance</a> and <a href="https://www.eurasiantimes.com/edited-drone-swarms-controlling-drone-swarms-pentagon/">striking</a> capabilities of combat drones by allowing for continuous information relay within groups of drones. </p>
<p>As research delves deeper into swarming, we find a world where collective action creates complexity, adaptability, and efficiency. As technology evolves, the role of swarm intelligence is set to grow, intertwining our world with the fascinating dynamics of swarms.</p><img src="https://counter.theconversation.com/content/209180/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Johnson receives funding from Biotechnology and Biological Sciences Research Council (BBSRC). </span></em></p>Research into swarming in nature is transforming healthcare, gambling and the military.Samuel Johnson, DPhil Candidate in Mathematical Biology, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2079732023-07-31T17:08:55Z2023-07-31T17:08:55ZQuébec’s cultural awareness training makes flawed assumptions that do not prioritize the safety of Indigenous people<figure><img src="https://images.theconversation.com/files/538194/original/file-20230719-17-vp87en.jpg?ixlib=rb-1.1.0&rect=31%2C116%2C2964%2C1913&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A protest demanding justice for Joyce Echaquan in Montréal in October 2020.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/quebecs-cultural-awareness-training-makes-flawed-assumptions-that-do-not-prioritize-the-safety-of-indigenous-people" width="100%" height="400"></iframe>
<p>Québec’s Minister Responsible for Relations with the First Nations and the Inuit, Ian Lafrenière, recently introduced <a href="https://www.assnat.qc.ca/en/travaux-parlementaires/projets-loi/projet-loi-32-43-1.html">Bill 32</a>, which aims to “establish the cultural safety approach within the health and social services network.” </p>
<p><a href="https://montrealgazette.com/news/quebec/quebec-bill-to-require-health-network-take-indigenous-cultural-safety-approach">The intent of the bill</a> is for health and social service networks in Québec to adopt a cultural safety approach towards Indigenous people, taking into account cultural and historical realities. </p>
<p>In November 2020, in the aftermath of the <a href="https://www.cbc.ca/news/canada/montreal/joyce-echaquan-systemic-racism-quebec-government-1.6196038">death of Joyce Echaquan</a> at the Centre hospitalier de Lanaudière in Joliette, the Québec government introduced <a href="https://www.ledevoir.com/societe/sante/589272/quebec-sensibilisera-les-travailleurs-de-la-sante-a-la-realite-autochtone">90-minute mandatory Indigenous cultural awareness training</a> for all employees of the province’s ministry of health and social services. </p>
<p>The goal of this training was to quickly sensitize health-care personnel to Indigenous cultures in order to improve the care provided for First Nations and Inuit Peoples in the Québec health and social services system. </p>
<p>It also aims to deconstruct myths and prejudices regarding Indigenous Peoples, to foster effective intercultural communication and to <a href="https://cdn.ciussscentreouest.ca/documents/ciusss-coim/Coin_des_employes/Formations/DAA_FAQ_formation_sensibilisation.pdf?1632505254">allow employees to better work with members of Indigenous communities</a>. </p>
<p>However, since the training program was launched, Indigenous leaders and health professionals have said it <a href="https://www.cbc.ca/news/indigenous/quebec-health-care-cultural-training-1.6593446">fails to improve cultural safety</a> and <a href="https://ici.radio-canada.ca/nouvelle/1917604/joyce-echaquan-formation-critique-realites-autochtones">poses safety risks to Indigenous Peoples</a>.</p>
<p>Legislating individuals and systems to shift behaviours and attitudes is useless without well-developed cultural safety programs developed and delivered by Indigenous Peoples.</p>
<h2>Cultural safety</h2>
<p>In April, we attended a round table on cultural safety organized by the Québe Network Environment for Indigenous Health Research on cultural safety alongside Indigenous scholars, patient partners and other community members in Montréal. Participants at the round table arrived to the same conclusions and supported concerns that the content of the mandatory training is <a href="https://www.cbc.ca/news/indigenous/quebec-health-care-cultural-training-1.6593446">inadequate and contains inaccuracies</a>. </p>
<p>In addition, important results and calls to actions from the <a href="https://www.rcaanc-cirnac.gc.ca/eng/1450124405592/1529106060525">Truth and Reconciliation Commission</a>, the <a href="https://www.cerp.gouv.qc.ca/fileadmin/Fichiers_clients/Rapport/Final_report.pdf">Viens Commission Report</a>, and the <a href="https://www.rcaanc-cirnac.gc.ca/eng/1448633299414/1534526479029">National Inquiry into Missing and Murdered Indigenous Women and Girls</a> are not mentioned during the training. Glaringly absent are also any references to the concept of cultural safety, cultural humility, systemic racism and <a href="https://principedejoyce.com/en/index">Joyce’s Principle</a> — which “aims to guarantee to all Indigenous people the right of equitable access, without any discrimination, to all social and health services.”</p>
<p>In this article, we assert that Québec’s training falls short of its objectives because it is based on three flawed assumptions about the problem at hand.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man holds a candle and a photo of a woman that reads: Justice pour Joyce" src="https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538367/original/file-20230719-19444-4i9jfv.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"></a>
<figcaption>
<span class="caption">A man attends a vigil for Joyce Echaquan, who died in a Québec hospital in September 2020. Indigenous leaders and health-care professionals have said cultural awareness training mandated after Echaquan’s death fails to improve safety for Indigenous people in Québec’s health-care system.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span>
</figcaption>
</figure>
<p><strong>1. Racism is an individual problem.</strong> </p>
<p>The focus on mandatory training as a solution to a systemic issue misrepresents the problem of racism as an individual problem of bias, attitudes and knowledge. Discrimination by health-care professionals should not be viewed only as individual acts, but as part of broader patterns of institutional and systemic racism.</p>
<p><a href="https://www.homelesshub.ca/resource/first-peoples-second-class-treatment-role-racism-health-and-well-being-indigenous-peoples">Researchers</a> and <a href="https://doi.org/10.1016/j.socscimed.2013.09.006">scholars</a> in this field assert that racism in health care needs to be understood in the context of past and current colonialism. </p>
<p>It is a fact that colonial policies of assimilation were based on a <a href="https://www.nccih.ca/docs/determinants/FS-Racism2-Racism-Impacts-EN.pdf">racist ideology that presupposed inferiority</a> of Indigenous Peoples. These policies have imprinted racist structures and stereotypes across institutions. </p>
<p>For instance, when analyzing the case of Echaquan, <a href="https://www.coroner.gouv.qc.ca/fileadmin/Enquetes_publiques/2020-06375-40_002__1__sans_logo_anglais.pdf">coroner Géhane Kamel revealed</a> her mistreatment took place in an environment that lacked culturally appropriate resources, was characterized by inequitable practices and tolerated racist attitudes and comments. </p>
<p>Understanding the problem of racial discrimination in health care means we must frankly and openly discuss contemporary colonialist and racist realities. To address systemic racism and its influence on health, we need to go beyond individual racial bias and address <a href="https://doi.org/10.1016/j.socscimed.2013.09.006">structural power inequalities</a>. Systemic racism needs systemic solutions, not individual ones. </p>
<p><strong>2. Racism, bias and stereotypes can be addressed through cultural sensitivity training.</strong> </p>
<p>The educational strategies that underlie the awareness training are insufficient to countering racism and fostering cultural safety. This is because the training program is based on a cultural sensitivity approach. However, numerous studies suggest this kind of training may <a href="https://doi.org/10.1093/intqhc/mzr008">reinforce negative stereotypes</a> of the concerned groups. </p>
<p>Cultural sensitivity tends to focus on having knowledge of a patient’s culture and reducing their experience of the health-care system to a matter of overcoming <a href="https://www.homelesshub.ca/resource/first-peoples-second-class-treatment-role-racism-health-and-well-being-indigenous-peoples">cultural differences</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A seated woman wearing glasses and holding papers speaks into a microphone." src="https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538370/original/file-20230719-19-ux8gy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In her report, Coroner Géhane Kamel called on the Québec government to acknowledge the existence of systemic racism and commit to eliminating it.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<p>Research shows that cultural <em>safety</em> is a better way to foster change. It compels us to examine the <a href="https://www.inspq.qc.ca/sites/default/files/publications/2870-formations-securisation-culturelle-sante-services-sociaux.pdf">power imbalances and racial inequities underlying the health-care system</a>. Cultural safety promotes an approach to foster change that moves away from simply learning about a culture. Instead, it aims to help staff <a href="https://www.inspq.qc.ca/sites/default/files/publications/2870-formations-securisation-culturelle-sante-services-sociaux.pdf">examine their own beliefs</a> and how these manifest in their interactions with Indigenous patients. </p>
<p>Scholars propose a conception of cultural safety as a systemic approach to health-care transformation, one that goes beyond individual training but engages organizations and society as a whole towards the principles of cultural safety, equity, social justice and decolonization. As such, comprehensive Indigenous cultural safety training programs should explicitly integrate notions of power, privilege, colonialism and racism. </p>
<p><strong>3. Cultural safety can’t be developed without involving the concerned groups.</strong> </p>
<p>The lack of meaningful involvement by Indigenous stakeholders is a critical weakness of the awareness training. However, cultural safety <a href="https://doi.org/10.2182/cjot.2012.79.3.4">privileges the autonomy</a> and self-determination of Indigenous Peoples in relation to their health services, and as such, promotes their empowerment. </p>
<p>The current awareness training does not significantly involve Indigenous stakeholders. <a href="https://www.cbc.ca/news/indigenous/quebec-health-care-cultural-training-1.6593446">It relies on few Indigenous perspectives and voices compared to non-Indigenous professors for instance</a>. This is contrary to the very concept of cultural safety. It also contradicts all the declarations, <a href="https://www.vch.ca/sites/default/files/import/documents/VCH-AH-ICS_Resources_Workbook_JAN21.pdf#:%7E:text=Many%20Indigenous%20communities%20live%20by%20the%20principle%20of,empower%20and%20facilitate%20sustainable%20change%20with%20Indigenous%20communities">protocols and principles</a> established by Indigenous groups in the last decades, which are based on the rallying cry “nothing about us without us.” </p>
<p>Cultural safety should be guided by the people it concerns. They are the only ones with the lived experience to share on the topic of safety and on the <a href="https://www.croakey.org/wp-content/uploads/2017/08/RAMSDEN-I-Cultural-Safety_Full.pdf">nature of the desired care</a>. </p>
<p>This approach to health-care transformation recognizes Indigenous expertise in designing solutions relevant to their needs. <a href="https://cerpe.uqam.ca/wp-content/uploads/sites/29/2016/08/Protocole-de-recherche-des-Premieres-Nations-au-Quebec-Labrador-2014.pdf">Cultural safety</a> is aligned with <a href="https://fnigc.ca/ocap-training/">principles that promote empowerment</a> and rely on values such as respect, equity and reciprocity. </p>
<p>In addition to failing to address the problems Indigenous people face, the training risks further marginalization and continued discrimination, as well as increased distrust of government and institutions among Indigenous populations. </p>
<p>For these reasons, this training should be immediately discontinued. To create a more equal health-care system, Indigenous people, organizations and health-care professionals — Indigenous or not — must have space to develop solutions based on cultural knowledge, lived experiences and their collective expertise. </p>
<p><em>The authors of this piece would like to acknowledge the significant contributions made to the article by the members of the Indigenous patient partner circles of the Unité de Soutien SSA Québec.</em></p><img src="https://counter.theconversation.com/content/207973/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Claude Tremblay receives funding from the Canadian Institutes of Health Research, the Fonds de recherche du Québec - Santé and the Fonds de recherche du Québec - Société et culture. </span></em></p><p class="fine-print"><em><span>Alex M. McComber receives funding from the CIHR for Pathways 3 project, but receives no personal funds.
He is affiliated with the Pathways Indigenous Advisory Committee with Boehringer Ingelheim for which he is compensated.
</span></em></p><p class="fine-print"><em><span>Georgia Limniatis receives funding from McGill University. </span></em></p>Cultural awareness training for health-care workers places focus on individual biases rather than tackling the systemic problems that negatively impact Indigenous patients.Marie-Claude Tremblay, Professeure agrégée, Département de médecine familiale et de médecine d'urgence, Chercheuse à VITAM, centre de recherche en santé durable, Université LavalAlex M. McComber, Assistant Professor of Family Medicine, McGill UniversityGeorgia Limniatis, DMD Candidate, Faculty of Dental Medicine and Oral Health Sciences, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2092572023-07-20T09:02:31Z2023-07-20T09:02:31ZPandemic healthcare disruptions led to more preventable hospital admissions – new research<figure><img src="https://images.theconversation.com/files/536558/original/file-20230710-15-wlbok3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pensive-senior-man-sitting-on-hospital-2314256183">Drazen Zigic/Shutterstock</a></span></figcaption></figure><p>It’s well known that the COVID pandemic created <a href="https://theconversation.com/five-ways-the-pandemic-has-affected-routine-medical-care-184712">unprecedented disruption</a> in how healthcare was provided and delivered globally. With the emergency phase of the pandemic now behind us, it’s important to understand if and how these disruptions affected people’s health.</p>
<p>In a <a href="https://www.bmj.com/content/382/bmj-2023-075133">new study</a> published in the BMJ, my colleagues and I have shown that people who were disrupted in accessing healthcare in England were more likely to be hospitalised for preventable conditions.</p>
<p>In England, non-emergency treatment, surgeries and diagnostic tests were postponed or cancelled. Appointments <a href="https://www.thelancet.com/journals/landig/article/PIIS2589-7500(21)00279-X/fulltext">were moved online</a>. Some treatment options were changed <a href="https://theconversation.com/coronavirus-has-forced-us-to-embrace-digital-healthcare-it-could-transform-how-we-look-after-patients-138557">to allow for their safe delivery</a> (for example, <a href="https://emj.bmj.com/content/39/8/575">monitoring blood oxygen levels</a> at home allowed people to be discharged earlier). Many of these changes were necessary to build capacity for treating COVID patients. </p>
<p>Meanwhile, staff <a href="https://theconversation.com/burned-out-heroes-why-bedside-nurses-should-not-have-to-be-martyrs-to-be-valued-184505">burnout</a> and <a href="https://theconversation.com/covid-19-2020-was-horrendous-for-health-workers-early-2021-was-even-worse-159503">illness</a> due to COVID or long COVID reduced the number of available healthcare workers.</p>
<p>Patients were also deterred from seeking healthcare, either for fear of being exposed to the virus or altruistic behaviour in not wanting to be a burden at a time of crisis. </p>
<p>While much of this was described at the time, there has been no empirical evidence that we know of to demonstrate the health effects of this disruption. We simply did not know how bad, if at all, this disruption would be. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-has-forced-us-to-embrace-digital-healthcare-it-could-transform-how-we-look-after-patients-138557">Coronavirus has forced us to embrace digital healthcare – it could transform how we look after patients</a>
</strong>
</em>
</p>
<hr>
<h2>Reviewing the data</h2>
<p>To investigate this, we used data on 29,276 people from seven large studies in England between March 1 2020 and August 25 2022. Each study sent several surveys to their participants during the pandemic to hear about their experiences, including in accessing healthcare.</p>
<p>People who participated in these surveys were then linked to their medical records by something called the <a href="https://ukllc.ac.uk/">UK Longitudinal Linkage Collaboration</a>. This provided us with a powerful way to see whether people who reported any disrupted healthcare were more or less likely to be hospitalised. </p>
<p>We focused on so-called “avoidable hospitalisations”. These are conditions that could have potentially been prevented with adequate access to healthcare (for example, gastric ulcers, angina and asthma).</p>
<p>We found that 35% of people had experienced some form of disruption in accessing healthcare during the first year of the pandemic. Some 26% of people had trouble accessing appointments (for example, visiting their GP or an outpatient department). And 18% were disrupted in receiving procedures (for example, postponed or cancelled surgery, changes to treatments offered or delays in accessing cancer treatment).</p>
<p>People who had faced any level of disruption were 80% more likely to be admitted to hospital for a potentially preventable condition up to the end of the study period. The effects were consistent when looking at short-term issues (such as gastric ulcers, dental problems and cellulitis) and chronic conditions (such as asthma, angina and high blood pressure).</p>
<figure class="align-center ">
<img alt="A number of patients and staff in a healthcare setting wearing masks." src="https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536570/original/file-20230710-25-6w6bzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Routine healthcare changed significantly at the height of the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nurse-senior-patient-going-hospital-examination-1804803289">DC Studio/Shutterstock</a></span>
</figcaption>
</figure>
<p>When we looked at which type of disruptions mattered most, our analyses suggested disruption to procedures was particularly significant. Disruptions in accessing appointments were also important. </p>
<p>Not everything was bad. Disrupted access to medications was uncommon (occurring for 6% of people) and we didn’t find meaningful associations between these experiences and hospital admissions. </p>
<p>Our study did have some limitations. Measuring the effects of healthcare disruption is hard. Linking specific moments of disruption to hospital admissions is impossible. Not all hospital admissions will have been due to disruptions in accessing care – some will have occurred anyway. </p>
<p>It’s also plausible that the full effects of disruption may not have occurred yet – it could take years to understand the total impact. For example, delays in cancer diagnosis due to postponed screening programmes might lead to poorer survival rates five years later if cancers are caught at later stages where they’re harder to treat.</p>
<h2>What can we learn?</h2>
<p>What we need to be doing now is learning about what worked and what didn’t in managing the COVID pandemic to help us prepare for the next pandemic. Our study suggests the importance of maintaining continued care, particularly in delivering treatments and procedures.</p>
<p>It’s of course easier to move GP appointments online than surgeries or treatments that need to be delivered in person. But focusing on preventing disruptions in delivering treatments is important in preparing for future pandemics.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-ways-the-pandemic-has-affected-routine-medical-care-184712">Five ways the pandemic has affected routine medical care</a>
</strong>
</em>
</p>
<hr>
<p>Our study also raises important questions about the need to clear backlogs of treatments, diagnostic tests, procedures and appointments. The NHS waiting lists <a href="https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/rtt-waiting-times-march-2023/">are at record levels</a> and we cannot continue to let them grow.</p>
<p>A challenging economy coupled with chronic under-investment in staff and infrastructure is going to make tackling these waiting lists and the longer-term effects of COVID disruption difficult. Ultimately, we need to increase <a href="https://theconversation.com/the-nhs-workforce-plan-is-a-good-start-but-a-lot-of-detail-is-missing-208886">investment in the NHS</a> to counter the legacy of COVID disruptions to healthcare.</p><img src="https://counter.theconversation.com/content/209257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was funded by the Medical Research Council, NHS Research Scotland, the Scottish Government Chief Scientist Office, Health Data Research UK and the National Institute for Health and Care Research. </span></em></p>About 35% of people in England faced some form of disruption to healthcare access during the pandemic.Mark Green, Reader in Health Geography, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2095102023-07-11T15:02:56Z2023-07-11T15:02:56ZGhana’s population is young and rapidly urbanising - policies need to match the data<figure><img src="https://images.theconversation.com/files/536735/original/file-20230711-19-sl30n6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ghana’s population can be described as rapidly urbanising and young</span> <span class="attribution"><span class="source">Wikimedia Commons/Flickr</span></span></figcaption></figure><p><em>Ghana’s population has reached 30.8 million according to the <a href="https://census2021.statsghana.gov.gh/presspage.php?readmorenews=MTQ1MTUyODEyMC43MDc1&Press-Release-on-Provisional-Results">2021 population census</a>. This is a 6.1 million increase from the 24.7 million recorded in 2010. Understanding population trends is important to inform development policies – but Ghana has struggled to design policies aligned to available data. Demographer Donatus Yaw Atiglo unpacks the key issues facing Ghana’s growing population.</em></p>
<h2>What is the age makeup of Ghana’s population?</h2>
<p>It is important to look at the trends in the changing population structure. </p>
<p>Ghana’s population can be described as rapidly urbanising and youthful. Over the past five censuses, we see the structure of the population pyramid change from predominantly children under 15 to young people (aged 15-35 years). </p>
<p>The age composition of Ghana’s <a href="https://census2021.statsghana.gov.gh/presspage.php?readmorenews=MTQ1MTUyODEyMC43MDc1&Press-Release-on-Provisional-Results">31 million</a> people, based on 2021 <a href="https://census2021.statsghana.gov.gh/presspage.php?readmorenews=MTQ1MTUyODEyMC43MDc1&Press-Release-on-Provisional-Results">census data</a>, indicates that about 35% are children (0-14 years), 38% young people (15-35 years), and about 4% are in the older population (65+). </p>
<p>A <a href="https://census2021.statsghana.gov.gh/gssmain/fileUpload/reportthemelist/Volume%203%20Highlights.pdf">higher concentration</a> (about 60%) of young people are in urban areas. This creates a pool of valuable labour, vibrant social participation as well as sources of creativity and innovation.</p>
<p>Overall, 60% are in the <a href="https://census2021.statsghana.gov.gh/gssmain/fileUpload/reportthemelist/Volume%203%20Highlights.pdf">working age population</a>. This suggests that there are fewer people in the dependent age groups relative to the working ages.</p>
<p>There is also a growing number of the elderly aged 65 and above, with implications for social security and healthcare. </p>
<p>The factor driving the change in the demographic profile is that women are having fewer children. The total fertility rate, which is the average number of children a woman has by the time she completes childbearing, assuming age-specific rates are held constant, has <a href="https://knoema.com/atlas/Ghana/Fertility-rate">declined </a>from about 6.4 births per woman in 1988 to 3.8 in 2021.</p>
<p>According to the <a href="https://statsghana.gov.gh/">Ghana Statistical Service</a>, the country’s population will double within 33 years. And by 2050, the population of Ghana will be over 50 million. Population growth implies boundless opportunities for economic and social development. But it also presents significant challenges and barriers to sustainable development, where economic and environmental resources cannot match population growth.</p>
<h2>Which age cohorts present the biggest challenges?</h2>
<p>Population scientists have associated the demographic dividend with growth in the working population relative to children and the elderly. The logic is that a lower dependency ratio – in other words a high number of people of working age versus very young and very old people – carries economic growth potential. Dependent age groups (children under 15 years and old people 65 years and above) have traditionally been considered a burdensome population. </p>
<p>But cashing in on the demographic dividend depends on the quality of human resources and the opportunities for the working population. Without skills and jobs, having a large proportion of young people could be a liability, not an asset. They need education, skills, healthcare and employment. </p>
<p>In Ghana the size of this cohort should be bringing a demographic dividend. But it isn’t because there is a growing proportion that isn’t in education, employment or training. </p>
<p>Another pressure point is growing urbanisation. Three out of five people live in an urban area, up from about <a href="https://census2021.statsghana.gov.gh/gssmain/fileUpload/reportthemelist/Volume%203%20Highlights.pdf">one out of every two in 2010</a> . This urban expansion has been largely unregulated, leading to a rise in urban poverty as well as overstretched infrastructure and social amenities. Over a quarter of urban residents live in <a href="https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/Multidimensional%20Poverty%20Ghana_Report.pdf">multidimensional poverty</a>. </p>
<p>Urban poverty, slum conditions, drug abuse, crime and unwanted pregnancies are all potential consequences of the large proportion of youth not in employment, education or training. </p>
<p>Older people are also a critical group that requires attention. People are living longer, with life expectancy at birth rising from 58 years in 2000 to <a href="https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=GH">65 years by 2020</a>. Older people have more health challenges and are therefore an increasing draw on a strained social security and health care systems.</p>
<h2>How aligned are Ghana’s policies towards its population challenges?</h2>
<p>Ghana has development policies on paper relating to health, education and gender. But the current mid- and long-term development policies of the country don’t consider population variables and the challenges they portend. </p>
<p>It behoves governments to consider population variables to identify future opportunities and challenges and guide resource allocation towards meeting the needs of the population. </p>
<p>Ghana failed to attain the main targets of the <a href="https://new-ndpc-static1.s3.amazonaws.com/pubication/Population+Policy_1994.pdf">1994 Population Policy</a>. These included reducing the total fertility rate to 3.0, increasing life expectancy to 70 and increasing the proportion of women with secondary plus education to 80% by 2020. </p>
<p>Ghana also failed to achieve key targets of the <a href="https://www.afdb.org/en/topics-and-sectors/topics/millennium-development-goals-mdgs">Millennium Development Goals</a>. These included eradicating extreme poverty and hunger, and reducing under-five mortality by two thirds and maternal mortality by three-quarters <a href="https://www2.statsghana.gov.gh/docfiles/2010phc/MDG%20report%20(24-10-13).pdf">between 1990 and 2015</a>. </p>
<p>But there is the potential to attain some targets of the <a href="https://www.undp.org/sustainable-development-goals/no-poverty?gclid=CjwKCAjw2K6lBhBXEiwA5RjtCQpQou19mHdshMyfj8isK1Vtn7iMvWwk0zgcCcZUb2yDvwUic_-JjxoCYscQAvD_BwE">Sustainable Development Goals</a> <a href="https://ghana.un.org/sites/default/files/2022-08/VNR_2022_Report_c5cXm4Q.pdf">related to equitable access to drinking water services, universal access to electricity by 2030</a>. </p>
<p>Ghana has made significant gains in improving access to healthcare, education, water and sanitation. This has reduced deaths from infectious diseases and improved life expectancy. </p>
<p>But there is more to be done to improve quality of life, attain the sustainable development goals related to poverty, food security, health and environment, and prepare the country for the demographic dividend. For instance, increased secondary school enrolment and completion have not been matched by employment and tertiary education opportunities. </p>
<p>In addition, previous policies have not prepared the country to deal with the double burden of communicable and non-communicable diseases.</p>
<h2>What are the key areas to focus on for development?</h2>
<p>Ghana needs to consider the different needs of different population groups. </p>
<p>When it comes to young people, it needs to make significant progress in relevant education and training, with matching employment opportunities. This matters for two reasons: so that fewer educated youth are unemployed or underemployed, and so that they contribute to social security. </p>
<p>The elderly need healthcare as they age. The burden of healthcare on their caregivers must be considered. We need to invest in geriatric care services to ensure quality of life for the ageing population. </p>
<p>All this requires the use of population data and integration of population variables into sustainable development planning to reduce inequalities and improve population well-being.</p><img src="https://counter.theconversation.com/content/209510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>D. Yaw Atiglo 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>Ghana’s implementation of key population policies has not been consistent.D. Yaw Atiglo, Research Fellow, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2084012023-07-05T10:48:07Z2023-07-05T10:48:07ZNHS at 75: problems abound but founding principles are unshaken<figure><img src="https://images.theconversation.com/files/535743/original/file-20230705-15-dnzr78.jpg?ixlib=rb-1.1.0&rect=5%2C1%2C992%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-february-3rd-2018-protesters-1017033559">Ink Drop/Shutterstock</a></span></figcaption></figure><p>The NHS has just turned 75, and the British public find themselves surrounded by jollity. There is a new logo, a 75th-anniversary badge, tea parties with cakes iced in blue, talks in schools, a photography competition, endless articles by people like me, and even some specially made bunting. </p>
<p>Is this 75th anniversary a cause for celebration or does it signal a system in old age, creaking its way into a sad decline? Should it be pensioned off? Or does the long-awaited <a href="https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/">workforce plan</a> signal investment in the NHS that could give it a new lease of life?</p>
<p>Certainly not everyone is celebrating. Not the 7.4 million people currently on a <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2023/06/Apr23-RTT-SPN-publication-version-PDF-427K.pdf">waiting list</a>, 370,000 of whom have been waiting for more than a year. Not the nurses, doctors, ambulance workers, porters and other staff involved in recent or planned strikes. </p>
<p>And certainly, today’s NHS faces many challenges. Some of them are new, most notably the COVID pandemic and its aftermath, but many are all too familiar.</p>
<p>Familiar challenges include increasing demand from an ageing population and from new technology, some of which is <a href="https://www.nature.com/articles/d41586-023-01389-z">unimaginably costly</a>. </p>
<p>Frail elderly patients with chronic disease have always needed hospital care, but success in helping patients to survive illnesses that would in the past have been life-threatening means that many people now have complex combinations of long-term conditions. </p>
<p>Over the past 75 years, public health pressures have changed somewhat. Undernutrition has been replaced by obesity, air pollution from burning coal has been replaced by air pollution from burning diesel, and industrial injuries have largely been replaced by a physically inactive population. </p>
<p>These different pressures are creating health problems, including diabetes and cardiovascular disease, which we need to learn more about how to prevent. Mental health problems are not new, but awareness of <a href="https://commonslibrary.parliament.uk/research-briefings/sn06988/">the extent of them may be</a>. Antibiotics, which helped the infant NHS survive, are increasingly losing their power, and the potential threat of antimicrobial resistance should not be underestimated. </p>
<h2>Exacerbated</h2>
<p>Many of these challenges face all health systems, but some have been exacerbated by UK policy choices. </p>
<p>2010-19 was the NHS’s <a href="https://www.nuffieldtrust.org.uk/news-item/what-was-austeritys-toll-on-the-nhs-before-the-pandemic">most austere decade ever</a>, and the strain was showing long before the shock of a pandemic. Waiting times for non-urgent surgery and visits to A&E and GPs were already rising, hospitals were in deficit, and there were problems with recruiting and keeping staff.</p>
<p>Lack of coordination of health and social care is also an old challenge. Creating a national health service alongside social care provided by local government generated tensions from the start. Healthcare was free at the point of use, and a clear national political priority. Social care was means-tested, and provided by local authorities with many competing objectives. Integrated care, so crucial to frail older people and those with complex conditions, remains elusive, and social care has <a href="https://www.kingsfund.org.uk/projects/positions/adult-social-care-funding-and-eligibility">long been under-resourced</a>.</p>
<p>And decades of inadequate workforce planning and reliance on international recruitment of health professionals, alongside new uncertainties relating to the <a href="https://www.nuffieldtrust.org.uk/news-item/has-brexit-affected-the-uk-s-medical-workforce">effect of Brexit</a> on the medical workforce, is severely constraining the NHS response to addressing the backlog of care post-COVID.</p>
<p>A recent <a href="https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-and-social-care-2022">national survey</a> of attitudes to the NHS and social care reveals real public concerns about the service. Overall satisfaction with the NHS fell to 29% in 2022, the lowest level since the survey began in 1983. </p>
<p>Satisfaction levels fell across the services: hospitals, dentistry, A&E and, most notably, general practice. When the survey respondents were asked what the most important priorities for the NHS should be, making it easier to get a GP appointment and increasing the number of staff were the most common choices.</p>
<p>The long-term workforce plan, released this week, attempts to address these priorities, and includes “the biggest recruitment drive in health service history”. The focus not only on training new staff but on improving ways of working and retaining those the NHS has, is certainly to be welcomed and seems to have cross-party support. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?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"></span>
</figcaption>
</figure>
<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
<hr>
<h2>Founding principles still supported</h2>
<p>Despite the very real concerns expressed by the <a href="https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-and-social-care-2022">public attitudes survey</a>, support for the founding principles of the NHS remains extremely strong: 93% of people believe that the NHS should be free of charge, and the vast majority believe it should be available to all and funded through taxation. </p>
<p><a href="https://harpercollins.co.uk/products/the-five-giants-a-biography-of-the-welfare-state-nicholas-timmins?variant=32798444945486">Historians</a> tell us that the NHS has been “in crisis” regularly since 1948. We have high and increasing expectations of what the NHS can do for us, and the <a href="https://theconversation.com/nhs-what-impact-will-a-32-hour-working-week-have-on-it-127578">labour-intensive nature of healthcare</a> means that we should expect it to cost more over time and to increase as a share of the overall economy. </p>
<p>Perhaps the NHS is showing some signs of frailty, but prophets of its imminent demise have been regularly proved wrong. Despite current challenges, the NHS survives and retains the principles of fair access and financial protection that were enshrined 75 years ago. I hope this will continue for another 75 years at least.</p><img src="https://counter.theconversation.com/content/208401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Bloor receives funding from the NIHR Policy Research Programme to provide responsive analysis to the Department of Health and Social Care.</span></em></p>Prophets of the NHS’s demise have been proved wrong year after year.Karen Bloor, Professor of Health Economics and Policy, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2084102023-07-05T09:53:00Z2023-07-05T09:53:00ZHow preventive healthcare could save the NHS – lessons from Finland, Japan and Singapore<p>If it’s true that an ounce of prevention is worth a pound of cure, preventive healthcare might really save the embattled NHS – now celebrating its 75th anniversary.</p>
<p>By promoting healthy lifestyles, early disease detection and timely treatment, the NHS could reduce chronic diseases such as type 2 diabetes, heart disease and cancer. And reducing the number of people with these chronic conditions would lead to a significant decrease in healthcare spending – which has been <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/funding/health-funding-data-analysis">steadily rising</a> in real terms since the NHS was founded. </p>
<p>The decision to follow this path wouldn’t seem so difficult if it weren’t for the small problem of figuring out how to do it and to what extent. </p>
<h2>How?</h2>
<p>Starting with the how, there are a few countries to look to for “best practice”. <a href="https://toolbox.finland.fi/life-society/finlands-healthcare-system/">Finland</a>, <a href="https://www.oecd-ilibrary.org/sites/9789264311602-6-en/index.html?itemId=/content/component/9789264311602-6-en">Japan</a> and <a href="https://www.hpb.gov.sg/healthy-living">Singapore</a>, for example, have implemented preventive programmes that focus on promoting healthy lifestyles, early disease detection through national screening programmes and disease management while paying attention to health education and public health campaigns. </p>
<p>Finland, meanwhile, has one of the lowest rates of cardiovascular disease in <a href="https://ehnheart.org/cvd-statistics/cvd-statistics-2017.html">Europe</a>, which has been attributed to the country’s comprehensive preventive healthcare initiatives. </p>
<p>The number of smokers among Finnish adults has decreased significantly <a href="https://pubmed.ncbi.nlm.nih.gov/35722986/#:%7E:text=Results%3A%20Smoking%20in%20Finland%20has,decrease%20to%2016%25%20in%202017.">over the past few decades</a>, thanks to government policies that discourage smoking. Under the Tobacco Act (2010) Finland aims to be tobacco and nicotine-free by 2030. </p>
<p>Finland was the first country to set such a goal in its national legislation.</p>
<figure class="align-center ">
<img alt="No smoking sign" src="https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535482/original/file-20230704-22-v6w5ik.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Finland has been very successful at stamping out smoking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/no-smoking-prohibited-signs-public-houses-1908161155">Chalermphon Srisang/Shutterstock</a></span>
</figcaption>
</figure>
<p>Singapore has been as successful as the Finns at getting the public <a href="https://www.moh.gov.sg/news-highlights/details/smoking-prevalence-in-s'pore-population-dropped-from-13.9-in-2010-to-10.1-in-2020#:%7E:text=These%20efforts%20have%20contributed%20to,10.1%20per%20cent%20in%202020.">to quit smoking</a>. It also has one of the lowest death rates from cardiovascular diseases <a href="https://ourworldindata.org/grapher/cardiovascular-disease-death-rates?tab=table&country=%7ESGP">in the world</a>. </p>
<p>And Japan has one of the highest life expectancies in the <a href="https://data.worldbank.org/indicator/SP.DYN.LE00.IN?most_recent_value_desc=true">world</a> and one of the lowest rates of people with metabolic syndrome (a group of risk factors for diabetes and heart disease) because of the country’s focus on healthy lifestyles. </p>
<p>The <a href="https://www.oecd-ilibrary.org/sites/9789264311602-6-en/index.html?itemId=/content/component/9789264311602-6-en#:%7E:text=The%20Health%20Japan%2021%20strategy%20provides%20a%20nation%2Dwide%20framework,smoking%20cessation%20and%20alcohol%20consumption.">Health Japan 21 strategy</a>, for instance, provides a nationwide framework to improve population health through interventions in workplaces, schools and local communities, focusing on diets, physical activity, smoking cessation and reducing alcohol consumption.</p>
<h2>How much?</h2>
<p>If the “how” sounds clear, the “how much” (to what extent and to what budget) is a little less clear. In the three countries mentioned, there have been very few studies on the economic impact of their preventive healthcare programmes. </p>
<p>In Finland, there is good evidence of the effectiveness of the <a href="https://read.oecd-ilibrary.org/social-issues-migration-health/finland-country-health-profile-2021_2e74e317-en#page12">Tobacco Act</a> and <a href="https://read.oecd-ilibrary.org/social-issues-migration-health/finland-country-health-profile-2021_2e74e317-en#page13">cancer screening programmes</a> on health, but the impact on healthcare expenditure is unclear. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?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"></span>
</figcaption>
</figure>
<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
<hr>
<p>In Singapore, the government frequently holds <a href="https://www.moh.gov.sg/news-highlights/details/preventive-care-spending-and-impact">question-and-answer sessions</a> on the costs of preventive healthcare and the impact of these programmes. While the evidence is stronger on the first question, not much is known about the effect of preventive health interventions on overall population health.</p>
<p>In Japan, <a href="https://www.mhlw.go.jp/stf/houdou/0000121935.html">a 2018 study</a> found that a check-up programme on diabetes prevented many people from starting dialysis treatment and reduced their healthcare use. According to this study, the healthcare spending of the participants in the programme was reduced by 20% between 2014 and 2015. But it is not known whether the study included the cost of targeted programmes when calculating the change in healthcare costs.</p>
<h2>Measure, measure, measure</h2>
<p>Maybe there’s something more the UK can learn from Japan, Finland and Singapore: if you’re going to invest in prevention, you need comprehensive measures of their effectiveness and efficiency.</p>
<p>So what should the UK measure? Assuming the goal of such a programme is to help people feel better while reducing NHS costs, the following would be useful things to track.</p>
<ul>
<li><p>Key preventive measures (such as data on vaccinations, screenings and preventive treatments) and risk factors (such as lifestyle choices, family history of diseases and demographics).</p></li>
<li><p>Information about health education and relevant health indicators to identify areas for improvement.</p></li>
<li><p>Outcomes, effects (such as disease incidence, hospital admission rates and overall population health improvements), costs and resource use.</p></li>
<li><p>Trends and predictions to forecast future healthcare needs. Identify emerging health risks and plan preventive interventions. </p></li>
</ul>
<p>And, most importantly, this information should be collected at the patient level to better measure the effects and to understand engagement with the programmes. Because an ounce of prevention is worth a pound of cure only if it’s true for each of us.</p><img src="https://counter.theconversation.com/content/208410/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesca Lecci 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>Finland aims to be tobacco free by 2030. Could the UK do more to keep the population healthy?Francesca Lecci, Associate Professor of Practice in Government, Health and Not for Profit, Bocconi UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2064572023-06-22T17:25:55Z2023-06-22T17:25:55ZListen: Widespread use of Ozempic for weight loss could change how we view fatness<figure><img src="https://images.theconversation.com/files/533549/original/file-20230622-19-53j2i3.jpg?ixlib=rb-1.1.0&rect=20%2C958%2C1943%2C1005&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ozempic, a semaglutide drug being used for weight loss, could impact how society sees fat people. </span> <span class="attribution"><span class="source">(macrovector/Freepik)</span></span></figcaption></figure><iframe height="200px" width="100%" frameborder="no" scrolling="no" seamless="" src="https://player.simplecast.com/325083d9-aeee-49a3-a16e-2ef5bdce4fad?dark=true"></iframe>
<p>It seems like everywhere you look these days, on TikTok, on the sides of buses, in news headlines, you see Ozempic, the drug originally created as a diabetes treatment, but now being used as a weight-loss method.</p>
<p>Ever since it <a href="https://globalnews.ca/news/9618159/ozempic-diabetes-weight-loss-drug-policy/#:%7E:text=Novo%20Nordisk%20actually,yet%20in%20Canada.">arrived in Canada</a>, it’s been in incredibly high demand. </p>
<p>While Ozempic may just be the next in a long line of get-thin-quick fads, it’s already causing a lot of issues, many of which are especially felt by racialized communities.</p>
<p><a href="https://dont-call-me-resilient.simplecast.com/episodes/widespread-use-of-ozempic-for-weight-loss-could-change-the-way-we-view-fatness">In this episode of <em>Don’t Call Me Resilient</em></a>, we are joined by fat and disability studies professor Fady Shanouda, who examines anti-fat bias in medicine. As the use of Ozempic, a drug for diabetes, slams into the mainstream as a weight-loss method, will the drug’s use impact our concept of fatness? And how does fatness intersect with race and class? How might the craze for Ozempic deepen racial and class disparities?</p>
<h2>Higher risk for diabetes</h2>
<p>In the United States and Canada, Black, Indigenous and South Asian communities are at a higher risk of Type 2 diabetes. A <a href="https://news.umanitoba.ca/rate-of-children-diagnosed-with-type-2-diabetes-rises-over-50-over-last-10-years-mchp-study-finds/">recent report</a> revealed that First Nations children in Manitoba are 25 times more likely to be diagnosed with Type 2 diabetes than other children. </p>
<figure class="align-left ">
<img alt="A person with their shirt pulled up and stomach exposed, with an ozempic injection in their right hand" src="https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533254/original/file-20230621-21-h6xfhj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A person prepares an Ozempic injection to use to control blood sugar levels.</span>
<span class="attribution"><span class="source">myskin/Shutterstock</span></span>
</figcaption>
</figure>
<p>The cost of Ozempic already puts certain communities at a disadvantage. In Canada, Ozempic costs around <a href="https://www.cbc.ca/news/canada/british-columbia/ozempic-canada-british-columbia-how-it-works-1.6794950">$300 a month</a> and in the U.S., the price is about <a href="https://www.webmd.com/obesity/news/20230503/ozempic-cost-coupons-and-ways-to-save-cash">$1,000 a month</a>. While many rely on health insurance for prescriptions, insurance for the most part does not cover Ozempic for non-diabetic use.</p>
<h2>The racist roots of fighting obesity</h2>
<p>Prof. Shanouda explains how fatness has been negatively associated with Blackness, both historically and currently. These harmful conceptions of fatness influences the treatment of racialized communities in health care. This includes <a href="https://www.newyorker.com/magazine/2023/03/27/will-the-ozempic-era-change-how-we-think-about-being-fat-and-being-thin">frequent misdiagnosis, under-treatment and frequent fat-shaming by doctors</a>.</p>
<blockquote>
<p>I imagine fat people will be asked all the time now: why they continue to be fat and why they’re not on Ozempic. It is presenting us with a supposed solution for a human variation that has existed for all time. There have always been fat people. There will always be fat people. - Fady Shanouda</p>
</blockquote>
<h2>Listen and Follow</h2>
<p>You can listen to or follow <em><a href="https://dont-call-me-resilient.simplecast.com/episodes/listen-to-an-american-canadian-trans-scholar-and-activist-explain-why-trans-rights-are-under-attack">Don’t Call Me Resilient</a></em> on <a href="https://podcasts.apple.com/ca/podcast/dont-call-me-resilient/id1549798876">Apple Podcasts</a>, <a href="https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5zaW1wbGVjYXN0LmNvbS9qZFg0Ql9DOA">Google Podcasts</a>, <a href="https://open.spotify.com/show/37tK4zmjWvq2Sh6jLIpzp7">Spotify</a> or <a href="https://dont-call-me-resilient.simplecast.com">wherever you listen to your favourite podcasts</a>. </p>
<p><a href="mailto:DCMR@theconversation.com">We’d love to hear from you</a>, including any ideas for future episodes. Join The Conversation on <a href="https://twitter.com/ConversationCA">Twitter</a>, <a href="https://www.facebook.com/TheConversationCanada">Facebook</a>, <a href="https://www.instagram.com/theconversationdotcom/">Instagram</a> and <a href="https://www.tiktok.com/@theconversation">TikTok</a> and use #DontCallMeResilient.</p>
<figure class="align-right ">
<img alt="A book cover with an drawing of Sara Baartman, and African women displayed in a zoo in 1800s England, for her body shape" src="https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533291/original/file-20230621-21-sf20hh.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sabrina Strings’s book cover for ‘Fearing the Black Body: The Racial Origins of Fat Phobia’ published by New York University Press.</span>
<span class="attribution"><span class="source">NYU Press</span></span>
</figcaption>
</figure>
<h2>Resources</h2>
<p><a href="https://www.scientificamerican.com/article/the-racist-roots-of-fighting-obesity2/">The Racist Roots of Fighting Obesity
</a> (<em>Scientific American</em>)</p>
<p><a href="https://www.nytimes.com/2023/06/14/health/obesity-drugs-wegovy-ozempic.html">New Obesity Drugs Come With a Side Effect of Shaming </a> (<em>The New York Times)</em></p>
<p><a href="https://news.yahoo.com/where-black-people-fit-ozepmic-140728627.html">Where do Black people fit into the Ozempic conversation?</a></p>
<p><a href="https://nyupress.org/9781479886753/fearing-the-black-body/"><em>Fearing the Black Body: The Racial Origins of Fatphobia</em></a> by Sabrina Strings</p>
<p><a href="https://www.inanna.ca/product/fat-studies-in-canada-remapping-the-field-in-canada/">Fat and Mad Bodies: Under, Out of, and Beyond Control</a> by Fady Shanouda in <em>Fat Studies in Canada: (Re)Mapping the Field</em></p>
<p><a href="https://www.huffpost.com/entry/why-im-nonbinary-but-dont-use-they-them_b_58ac875ee4b05e6b9b192c07">Why I’m Non-Binary But Don’t Use ‘They/Them’</a> by Hunter Ashleigh Shackelford</p>
<p><a href="https://www.press.umich.edu/11700274/queer_nightlife">Jockstraps and Crop Tops: Fat Queer Femmes Dressing for the Night</a> by Caleb Luna in <em>Queer Nightlife</em></p>
<h2>Read more in The Conversation</h2>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ozempic-helps-weight-loss-by-making-you-feel-full-but-certain-foods-can-do-the-same-thing-without-the-side-effects-201870">Ozempic helps weight loss by making you feel full. But certain foods can do the same thing – without the side-effects</a>
</strong>
</em>
</p>
<hr>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fatblaster-max-has-just-been-banned-why-heres-everything-you-need-to-know-about-diet-supplements-183347">FatBlaster Max has just been banned. Why? Here’s everything you need to know about diet supplements</a>
</strong>
</em>
</p>
<hr>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-true-the-faster-you-lose-weight-the-quicker-it-comes-back-heres-what-we-know-about-slow-and-fast-weight-loss-198301">Is it true the faster you lose weight the quicker it comes back? Here's what we know about slow and fast weight loss</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/206457/count.gif" alt="The Conversation" width="1" height="1" />
As the use of Ozempic, a drug for diabetes, slams into the mainstream as a weight-loss method, will the drug’s use impact our concept of fatness? And how does fatness intersect with race and class?Vinita Srivastava, Host + Producer, Don't Call Me ResilientBoké Saisi, Associate Producer, Don't Call Me ResilientKikachi Memeh, Assistant Producer/Student Journalist, Don't Call Me ResilientLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2079122023-06-20T03:39:54Z2023-06-20T03:39:54ZAI is already being used in healthcare. But not all of it is ‘medical grade’<figure><img src="https://images.theconversation.com/files/532806/original/file-20230620-15-4n4270.jpg?ixlib=rb-1.1.0&rect=116%2C0%2C6285%2C3520&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/technology-background-binary-code-flying-through-1108438682">Shutterstock</a></span></figcaption></figure><p>Artificial intelligence (AI) seems to be everywhere these days, and healthcare is no exception.</p>
<p>There are computer vision tools that can <a href="https://doi.org/10.1126/scitranslmed.abb3652">detect suspicious skin lesions</a> as well as a specialist dermatologist can. Other tools can predict coronary artery disease <a href="https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.119.044666">from scans</a>. There are also <a href="https://ieeexplore.ieee.org/abstract/document/9805581">data-driven robots</a> that guide minimally-invasive surgery.</p>
<p>To <a href="https://doi.org/10.1139/gen-2020-0131">precisely diagnose diseases</a> and guide <a href="https://doi.org/10.3389/fpsyt.2018.00290">treatment choices</a>, AI is used to analyse patients’ genomic and molecular data. For instance, machine learning has been applied to detect <a href="https://doi.org/10.1038/s41598-018-29433-3">Alzheimer’s disease</a> and to help <a href="https://doi.org/10.3389/fpsyt.2018.00290">choose the best antidepressant medication</a> for patients with major depression.</p>
<p><a href="https://www.ibm.com/topics/deep-learning">Deep learning</a> methods have been used to model electronic health record data to <a href="https://doi.org/10.1038/s41746-018-0029-1">predict health outcomes for patients</a> and provide <a href="https://doi.org/10.1038/s41746-021-00474-9">early estimates of treatment cost</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-to-z-all-the-terms-you-need-to-know-to-keep-up-in-the-ai-hype-age-203917">AI to Z: all the terms you need to know to keep up in the AI hype age</a>
</strong>
</em>
</p>
<hr>
<p>With new language-based generative AI technologies like ChatGPT, the clinical world is abuzz with talk of <a href="https://dx.doi.org/10.1001/jamainternmed.2023.1838">chatbots for answering patient questions</a>, helping doctors <a href="https://www.nejm.org/doi/10.1056/NEJMsr2214184">take better notes</a>, and even <a href="https://unlocked.microsoft.com/ai-anthology/case-studies/#medicine">explaining a diagnosis</a> to a concerned grandchild.</p>
<p>There is no doubt that in terms of patient health, workflows and system efficiency, AI will benefit the health system. </p>
<p>But there are legitimate concerns about the accuracy of such tools, including how well they work in new settings (such as a different country or even a different hospital from where they were created), and whether they “hallucinate” – or make things up. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An operating room with no people and only several robot arms hovering above a patient" src="https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532809/original/file-20230620-20-ukwdt.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"></a>
<figcaption>
<span class="caption">Robot-assisted surgery is already the reality in some technologically equipped hospitals.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctors-using-modern-technology-treat-robots-1037827384">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Developing ‘medical grade’ tools</h2>
<p>In our <a href="https://doi.org/10.5694/mja2.51992">recent article</a> in the Medical Journal of Australia, we argue using AI effectively in healthcare will require retraining of the workforce, retooling health services, and transforming workflows.</p>
<p>Critically, we also need to collect evidence AI tools are “medical grade” before we use them on patients. </p>
<p>Many claims made by the developers of medical AI may <a href="https://doi.org/10.1016/s2589-7500(19)30123-2">lack appropriate scientific rigour</a> and evaluations of AI tools may suffer from a <a href="https://doi.org/10.1136/bmj.m689">high risk of bias</a>. This means the tests run to ensure their accuracy are too narrow.</p>
<p>AI tools can make errors, or stop working when the application context changes. Conversational agents such as chatbots may produce misleading medical information that may delay patients seeking care. They may also make <a href="https://doi.org/10.2196%2F15823">inappropriate recommendations</a>.</p>
<p>All this means we need standards for the AI tools that impact diagnosis and treatment of patients. Clinicians should be given training on how to <a href="https://doi.org/10.1136%2Fbmjhci-2020-100251">critically assess</a> AI applications to understand their readiness for routine care. </p>
<p>We should expect to be able to replicate the results from one context to another, under real-world conditions. For example, a tool developed using historical data from a hospital in New York should be carefully trialled with live patient data in Broome before we trust it.</p>
<p>Randomised controlled trials of AI tools, where these differences are controlled for, would represent a gold standard of evidence for their use. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-has-potential-to-revolutionise-health-care-but-we-must-first-confront-the-risk-of-algorithmic-bias-204112">AI has potential to revolutionise health care – but we must first confront the risk of algorithmic bias</a>
</strong>
</em>
</p>
<hr>
<h2>We can’t just copy what other countries do</h2>
<p>It is important to carefully examine <a href="https://doi.org/10.1093/jamia/ocac121">how AI tools are embedded into workflows</a> to support clinical decisions. The benefits and risks of a tool will depend on precisely <a href="https://doi.org/10.1136%2Fbmjhci-2020-100301">how the human clinician and the tool work together</a>.</p>
<p>There’s a view that all we need to do in Australia is adopt the best of what is produced internationally, and that we don’t need deep sovereign capabilities.</p>
<p>Perhaps we can rely on the regulation of AI tools under way through the European Union’s <a href="https://artificialintelligenceact.eu/">AI Act</a>, or the United States Food and Drug Administration’s processes for assessing <a href="https://www.fda.gov/medical-devices/software-medical-device-samd/artificial-intelligence-and-machine-learning-software-medical-device">Software as a Medical Device</a>. </p>
<p>Nothing is further from the truth.</p>
<p>AI requires local customisation to support local practices, and to reflect diverse populations or health service differences. We don’t want to just export our clinical datasets and import back the models built with them without adapting to our contexts and workflows. We need to monitor the clinical deployments of AI tools into our settings. </p>
<p>Without some degree of algorithmic sovereignty – the capability to produce or modify AI in Australia – the nation is exposed to new risks and the benefits of the technology will be limited. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-should-australia-capitalise-on-ai-while-reducing-its-risks-its-time-to-have-your-say-206863">How should Australia capitalise on AI while reducing its risks? It's time to have your say</a>
</strong>
</em>
</p>
<hr>
<h2>A roadmap for AI in Australian healthcare</h2>
<p>The Australian Alliance for Artificial Intelligence in Healthcare has produced <a href="https://aihealthalliance.org/wp-content/uploads/2021/12/AAAiH_Roadmap_1Dec2021_FINAL.pdf">a roadmap</a> for future development. </p>
<p>It identifies gaps in Australia’s capability to translate AI into effective and safe clinical services and provides guidance on key issues such as workforce, industry capability, implementation, regulation, and cybersecurity. </p>
<p>These recommendations offer a path toward an AI-enabled Australian healthcare system capable of delivering personalised and patient-focused healthcare, safely and ethically. </p>
<p>The plan also envisages a vibrant AI industry sector that creates jobs and exports to the world, working side by side with an AI-aware workforce and AI-savvy consumers.</p>
<p>AI has the potential to transform medicine. It can do so by harnessing computational power to discern subtle patterns in complex data spanning biology, images, sensory and experiential data, and more.</p>
<p>With care and strategic investment, innovations in AI will surely benefit clinicians and patients alike. Now is the time to act to ensure Australia is well-placed to benefit from one of the most significant industrial revolutions of our time.</p><img src="https://counter.theconversation.com/content/207912/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karin Verspoor receives funding from the NHMRC and the ARC. She serves as a Board member of BioGrid Australia. Karin is a co-founder of the Australian Alliance for Artificial Intelligence in Healthcare, along with the other authors of this article. </span></em></p><p class="fine-print"><em><span>David Hansen receives funding from NHMRC. David serves as a Board member of Australasian Institute of Digital Health. David is a co-founder of the Australian Alliance for Artificial Intelligence in Healthcare, along with the other authors of this article.</span></em></p><p class="fine-print"><em><span>Enrico Coiera receives funding from NHMRC. Enrico is a shareholder and Board member of
Evidentli, a digital health company. Enrico is a co-founder of the Australian Alliance for Artificial Intelligence in Healthcare, along with the other authors of this article.</span></em></p>Using AI effectively in healthcare will require retraining of the workforce, retooling health services, and transforming workflows.Karin Verspoor, Dean, School of Computing Technologies, RMIT University, RMIT UniversityDavid Hansen, CEO, Australian e-Health Research Centre, CSIROEnrico Coiera, Professor of Medical Informatics, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2052332023-06-07T14:04:05Z2023-06-07T14:04:05ZFoetal alcohol syndrome: facial modelling study explores technology to aid diagnosis<figure><img src="https://images.theconversation.com/files/530314/original/file-20230606-17-xwgadc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Advances in facial recognition technology may have useful applications in healthcare.</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Foetal alcohol syndrome is a lifelong condition <a href="https://www.nhs.uk/conditions/foetal-alcohol-spectrum-disorder/">caused</a> by exposing an unborn baby to alcohol. It’s a pattern of mental, <a href="https://doi.org/10.1111/j.1469-7580.2006.00683.x">physical</a> and behavioural symptoms seen in some people whose mothers consumed alcohol during pregnancy. Not all prenatal alcohol exposure results in the syndrome; it is the most severe form of a range of effects called foetal alcohol spectrum disorders. </p>
<p>South Africa has the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710622/">highest reported rates</a> of <a href="https://theconversation.com/explainer-foetal-alcohol-spectrum-disorders-9871">foetal alcohol spectrum disorders</a> in the world: 111.1 per 1,000 population. The disorders may affect <a href="https://farrsa.org.za/library/#toggle-id-2">seven million</a> people in the country. The number could be higher because of under-diagnosis. </p>
<p>Foetal alcohol syndrome can’t be reversed. But confirmed diagnosis can have benefits. It can lead to early intervention and therapy (physical, occupational, and speech, among others), and a better <a href="https://farrsa.org.za/wp-content/uploads/2021/11/2021-FASD-Pamphlet-13-Sept-2021.pdf">understanding</a> from parents and teachers. Diagnosis can also ensure that adults are eligible for social services support. </p>
<p>Clinicians use a range of methods to <a href="https://publications.aap.org/pediatrics/article/138/2/e20154256/52445/Updated-Clinical-Guidelines-for-Diagnosing-Fetal">diagnose foetal alcohol syndrome</a>, including assessing abnormal growth and brain function. A key part of the process is looking at the individual’s facial features. Typical <a href="https://farrsa.org.za/library/#toggle-id-1">features</a> are small eye openings, a thin upper lip, and a smooth area between the nose and upper lip. </p>
<p>But visual examination of the facial features can be subjective and often depends on the clinician’s experience and expertise. Another challenge arises in low-resource settings when there aren’t many doctors specially trained to do this.</p>
<p>A more objective and standard way to detect foetal alcohol syndrome early would therefore be useful.</p>
<p>One method that’s being used to aid diagnosis is <a href="https://doi.org/10.1111/acer.14875">three-dimensional (3D) surfaces</a> produced by devices that scan the face. The technology is costly and complex. Two-dimensional (2D) images are easier to get – it can be done with a digital camera or smartphone – but are not accurate enough for diagnosis.</p>
<p><a href="https://doi.org/10.17159/sajs.2023/12064">Our study</a> sought to explore whether it was possible to use normal 2D face images to approximate 3D surfaces of the face. We showed that it was. Our method involved using 3D models that can change their shape based on a variety of real human faces, combined with 3D facial analysis technology.</p>
<p>We argue in our paper that our findings show the technology can improve early detection, intervention and treatment for people affected by foetal alcohol syndrome, particularly in low-resource settings. </p>
<p>We hope to contribute to the global effort to prevent and manage the lifelong consequences of the syndrome and disorders.</p>
<h2>How it would work</h2>
<p>We constructed a <a href="https://doi.org/10.1145/3395208">flexible 3D model</a> that can alter its shape based on a variety of real human faces. The changes are guided by statistical patterns learned from a <a href="https://www.cs.binghamton.edu/%7Elijun/Research/3DFE/3DFE_Analysis.html">dataset of high-quality 3D scans</a> from 98 individuals. This international open-source dataset was carefully curated to represent different demographic groups. </p>
<p>We didn’t have access to image data of individuals affected by foetal alcohol syndrome. We therefore used 2D and 3D images of individuals without this condition to develop and validate our approach. We nevertheless reasoned that our method should work equally well for any scenario where the model and the test subjects are closely matched. </p>
<p>We then set out to develop and validate a machine learning algorithm for predicting 3D faces of unseen subjects, from their 2D face images only, using our 3D model. </p>
<p>This was a pioneering step in our research, where we aimed to create a “smart” tool that could bring flat images to life in three dimensions. The results of the study were encouraging. </p>
<p>Our 3D-from-2D prediction algorithm performed well in three ways:</p>
<ul>
<li><p>capturing facial variations</p></li>
<li><p>representing unique features</p></li>
<li><p>summarising information of faces from 2D images. </p></li>
</ul>
<p>Since we had actual 3D face scans to use for comparison, we were able to calculate the average difference between these scans and the face shapes predicted by our model. This allowed us to measure the error in our fitting, which we found to be in <a href="https://doi.org/10.1109/TCYB.2014.2359056">line with other studies</a>. </p>
<p>We particularly focused on specific regions of the face: the eyes, midface, upper lip, and philtrum (the groove between the nose and the top lip). These regions provide crucial information for clinicians when examining the facial markers of foetal alcohol syndrome. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530325/original/file-20230606-28-vgz1xs.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Facial regions associated with foetal alcohol syndrome on a normal face.</span>
<span class="attribution"><span class="source">Tinashe Mutsvangwa</span></span>
</figcaption>
</figure>
<p>We could accurately predict these facial regions, and concluded from this that our method could form the foundation of an image-based diagnostic tool for foetal alcohol syndrome.</p>
<p>Our study also showed that the quality of our predictions was independent of skin tone. This is a crucial finding. <a href="https://doi.org/10.1179/1743131X14Y.0000000093">Certain 3D scanning technologies have been known to struggle with accurately capturing darker skin tones</a>. This issue is <a href="https://doi.org/10.1016/j.bjps.2019.05.002">being addressed</a>. Nevertheless, our findings gave us confidence that there was additional potential for use of our approach in diverse populations. </p>
<h2>Challenges</h2>
<p>We did identify some limitations. Access to 3D data of individuals with foetal alcohol syndrome remains a challenge. Future research could focus on reducing reconstruction errors to acceptable clinical standards by collecting and analysing larger datasets, including data from underrepresented populations.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/remembering-tania-douglas-a-brilliant-biomedical-engineer-academic-and-friend-161931">Remembering Tania Douglas: a brilliant biomedical engineer, academic and friend</a>
</strong>
</em>
</p>
<hr>
<p><em>Our study is a continuation of the work carried out in collaboration with the late renowned South African biomedical engineer, <a href="https://sajs.co.za/article/view/11067">Tania Douglas</a> of the University of Cape Town.</em></p><img src="https://counter.theconversation.com/content/205233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tinashe Ernest Muzvidzwa Mutsvangwa receives funding from the South African National Research Foundation</span></em></p><p class="fine-print"><em><span>Bernhard Egger receives funding from the German research council. </span></em></p><p class="fine-print"><em><span>Felix Atuhaire received funding from European Commission; the South African Department of Science and Innovation; the South African National Research Foundation.</span></em></p>Key to diagnosing foetal alcohol syndrome is an assessment of certain facial features. A 3D facial scan is expensive but 2D images may offer a solution.Tinashe Ernest Muzvidzwa Mutsvangwa, Associate Professor of Biomedical Engineering, University of Cape TownBernhard Egger, Professor for Cognitive Computer Vision, Friedrich-Alexander-Universität Erlangen-NürnbergFelix Atuhaire, Lecturer, Mbarara University of Science and TechnologyLicensed as Creative Commons – attribution, no derivatives.