Wednesday, 29 February 2012
This paper is the first in a series looking at interactions between the NHS, individuals and communities. A further four papers in the run up to the 2012 NHS Confederation annual conference and exhibition will explore: putting people first through shared decision-making; information and the power paradigm; micro-enterprises and building community assets; and building social value within the system and society.
Health secretary responds to emergency question from Labour counterpart after apparent discord within coalition
Andrew Lansley declared on Tuesday that the latest amendments to his controversial NHS reform bill would be "significant".
The health secretary was responding to an emergency question from his Labour shadow, Andy Burnham, after the coalition government's apparent confusion over the changes announced on Monday by the Liberal Democrat deputy prime minister Nick Clegg.
In an effort to head off a backlash against the health and social care bill from within his party at its spring conference in March, Clegg wrote to his MPs and peers promising important changes to "rule out beyond doubt any threat of a US-style market in the NHS".
However the promise of five new amendments through the House of Lords was undermined by his Conservative coalition partners after Downing Street said that the changes would be "not significant". On Friday, and at lunchtime on Monday, government ministers had also said there would be no further changes to the bill.
Burnham challenged Lansley to tell MPs whether the latest changes were "substantial or cosmetic", and whether they had been agreed by the prime minister and health secretary in advance.
"The government appears in complete disarray, or maybe it was … coalition choreography to save face for the deputy prime minister," said Burnham. "The NHS matters too much to leave it to be carved up in cosy coalition deals."
Lansley avoided at least three times answering questions about whether he had been consulted about Clegg's letter. "The point of the letter was to reflect the discussions we have been having," he said in reply to Labour MP Gisela Stuart, apparently referring to the government and the House of Lords, which has discussed amendments in the committee and now report stages. "The amendments to the report would, by their nature, be significant," he added later.
Labour MP Rushanara Ali challenged Lansley on the decision by Tower Hamlets clinical commissioning group, in her constituency, to ask the health secretary to drop the bill. "When the very structures he's establishing to advise him are telling him they don't want to have part to do with this nightmare he's creating, isn't it time to look again and drop the bill?" she asked.
Lansley replied: "They will use the powers in this bill and they will use them effectively."
Later Burnham also criticised the decision of the backbench business committee of MPs, which decided not to hold a debate on the e-petition signed by 162,000 people asking for the health bill to be dropped. E-petitions hosted by the government website are eligible to be debated when they are signed by more than 100,000 people. The Guardian
Draft report into treatment of elderly people in hospitals and care homes says 'fundamental changes' needed across the board
Nurses, doctors and care workers should be recruited as much for their compassion as for their exam results, according to an inquiry into improving the dignity of treatment of elderly people in hospitals and care homes.
A shake-up of the criteria used for selecting and appraising staff should give the same emphasis to their assessed values and capacity to engage with older people as to their formal qualifications, the inquiry recommends. But it stops short of backing any lowering of academic entry bars.
The call is among a raft of proposals by a commission set up jointly by bodies representing NHS organisations and local councils together with a leading charity for older people, following a series of reports and investigations exposing poor care in hospitals and care homes.
A dossier of cases published 12 months ago by the NHS ombudsman found failure to provide "even the most basic standards of care". Later this spring, the conclusions of the Francis inquiry into the breakdown of care at hospitals in mid-Staffordshire is expected to damn the quality of nursing and medical and management supervision.
The draft report of the Commission on Dignity in Care, published on Wednesday, says that improving matters will require nothing short of "fundamental changes to culture, leadership, management, staff development, clinical practice and service delivery".
Sir Keith Pearson, chair of the NHS Confederation, which represents health trusts, said there had been too many cases of failings in care. "We want this report to be a call to arms to the whole health and social care system. We need to work together to earn back public confidence."
The report, which is open to public consultation, urges an end to "command-and-control" NHS management that it says has disempowered frontline staff. It calls on nursing sisters to be given responsibility for everything that happens on their ward and "take the action they deem necessary in the interests of patients", and says that ward teams should have daily discussions on feedback from patients and relatives, with regular reports going up to trust boards.
Residents and their relatives should be involved in the running of care homes, the report says, and a national care quality forum should be set up to investigate all aspects of the staffing of homes, including pay and qualifications, as part of a drive to raise the status of work in the care sector.
Trish Morris-Thompson, NHS London's chief nurse and a member of the commission, said that recruitment and regular career appraisal of staff should consider their values and compassion as much as academic rigour. A pilot scheme involving Great Ormond Street children's hospital in London and the South Bank University nursing course had produced graduates of exceptional quality.
Katherine Fenton, chief nurse at University College London Hospitals foundation trust, said her trust was taking a similar approach, starting with medical consultants, involving assessment of their interaction with patients and group interviews.
The commission insists that many of its recommendations could be implemented at minimal cost. The University Hospitals Birmingham foundation trust, which is singled out for praise in the report, is said to have established a comprehensive "dignity for all" programme with what Morris-Thompson described as "very little resource".
Nearly 50,000 hip-replacement patients will need annual medical checks as evidence grows that their metal implants can cause serious health problems, including severe pain and long-term disability. A leading manufacturer of the implants has known about potential dangers to patients since at least 2005, internal documents have revealed. Health regulators and the Department of Health have been aware since 2006. The Independent
Nurses should be assessed for their compassion, as well as their academic ability, when they are hired by hospitals and care homes, the Commission for Improving Dignity in Care of Older People recommends. The Independent
Mentally ill people are four times more likely to be victims of violence, the BBC has today reported.
This alarming statistic is based on a review of research looking at how often people with a range of disabilities had experienced violence in the previous year, and how this compared with non-disabled people. After combining the results of 26 previous studies, researchers found that more than 24% of those with a mental illness had been physically attacked in the previous year, as had more than 6% of people with intellectual impairments and more than 3% of people with all types of disability. People with disabilities were generally more at risk of violence than non-disabled individuals.
Although it had some limitations, this large well-conducted review supports previous research suggesting that people with disabilities are at increased risk of violence, and those with mental illness are particularly vulnerable. Most of the previous studies it looked at were in high-income countries including the UK, so the findings are particularly relevant for this country.
Further research on this important issue is now required to understand the magnitude of the problem in the UK and to develop further public health strategies to protect vulnerable groups.
Where did the story come from?
The study was carried out by researchers from Liverpool John Moores University and the World Health Organization (WHO). It was funded by the WHO Department of Violence and Injury Prevention and Disability. The study was published in the peer-reviewed medical journal The Lancet.
The BBC’s report was fair and included comments from independent UK experts.
What kind of research was this?
This was a systematic review and meta-analysis combining the results of previous research on violence against people with disabilities. It looked both at studies reporting on the rates of recorded violence against disabled adults, and at those that examined risk of violence to disabled adults compared with non-disabled adults.
The authors point out that about 15% of adults worldwide have a disability, a figure that is predicted to increase because of ageing populations and the rise in chronic disease, including mental illness. People with disabilities seem to be at increased risk of violence because of several factors including exclusion from education and employment, the need for personal assistance with daily living, communication barriers and social stigma and discrimination. The authors also say that there is an increasing number of media reports highlighting cases of physical violence and sexual abuse of disabled individuals living in institutions, but point out that formal research to quantify the problem is scarce.
What did the research involve?
The authors searched 12 online research databases to identify any studies that had reported on the prevalence of violence against adults with disabilities, or their risk of violence compared with non-disabled adults. They searched for all relevant studies published between 1990 and 2010. They also used additional methods to look for further studies, including hand searching reference lists and web-based searches.
To be deemed suitable for inclusion, studies had to meet various criteria. For example, their design had to be either a cross-sectional, case-control or cohort, they had to report on specific disability types, and they had to report violence occurring within the 12 months prior to the study.
All the identified studies were independently assessed by two separate reviewers using accepted criteria for assessing the quality of research. Individuals in the studies were grouped according to the type of disability: non-specific impairments (physical, mental, emotional or other health problems), mental illness, intellectual impairments, physical impairments and sensory impairments. The types of violence examined were physical violence, sexual violence, intimate partner violence and any violence.
The researchers calculated prevalence rates and the risk of violence faced by disabled people compared with non-disabled people, using standard statistical methods.
What were the basic results?
The researchers’ initial search identified 10,663 studies on the subject, but only 26 were eligible for inclusion. Overall, these studies provided data on 21,557 individuals with disabilities.
Of these studies, 21 provided data on the prevalence of violence among disabled people, and 10 provided data on the risk of violence compared with non-disabled people. By combining their results, researchers found that over the previous year:
- 24.3% of mentally ill adults had been subjected to violence of any type (95% CI: 18.3 to 31.0%)
- 6.1% of adults with intellectual impairments had been subjected to violence of any type (95% CI: 2.5 to 11.1%)
- 3.2% of adults with any impairment had been subjected to violence of any type (95% CI: 2.5 to 4.1%)
However, the researchers did note significant differences between individual studies (heterogeneity) in their prevalence estimates. Heterogeneity provides an indicator of how suitable it is to combine the results of different studies, with greater heterogeneity suggesting studies are of lower compatibility with each other.
When they pooled the results of studies comparing disabled with non-disabled individuals they found that, overall, disabled people were 1.5 times more likely to have been attacked than non-disabled people (odds ratio: 1.5; 95% CI: 1.09 to 2.05).
There was also a trend for people with specific types of disability to experience more violence, but not all associations were significant:
- People with intellectual impairments were 1.6 times more likely to have been physically attacked than people without intellectual impairments (results from three studies; pooled odds ratio: 1.60; CI 95%: 1.05 to 2.45).
- Mentally ill people were no more likely to have been physically attacked than non-mentally ill people (three studies; pooled odds ratio: 3.86; 95% CI: 0.91 to 16.43).
- People with non-specific impairments were no more likely to have been physically attacked than those without (six studies; pooled odds ratio: 1.31; 95% CI: 95% 0.93 to 1.84).
How did the researchers interpret the results?
The researchers conclude that adults with disabilities are at a higher risk of violence compare with non-disabled adults, and that those with mental illnesses could be particularly vulnerable. However, they add that the available studies have methodological weaknesses and that gaps exist in the types of disability and violence they address. They also point out that good studies are absent for most regions of the world, particularly low-income and middle-income countries.
Violence and abuse against anyone is not acceptable, but there is an even greater need to ensure that vulnerable groups who may be less able to help themselves receive adequate protection against this type of victimisation. This valuable systematic review helps to establish the proportion of people with disabilities who have experienced violence, as well as how this compares to people without disabilities. The estimates it provides may prove useful for planning services and policies to protect vulnerable individuals such as people with mental health issues.
However, the review does have several limitations, many of which the authors acknowledge:
- The studies were limited to looking at violence within the 12 months before each study, which means the review probably underestimates people’s lifetime exposure to violence.
- It is not clear from some of the studies whether the violence was a cause or a result of people’s health conditions, i.e. whether disability led to violence, or if violence caused people to develop disability such as mental health issues. This factor could particularly affect studies of people with mental illness, which form a large proportion of the studies included.
- The studies included in the review varied in quality, with only one achieving the assessors’ maximum quality scores. The researchers say that combining the results of individual studies was severely hindered by lack of methodological consistency between studies, including variations in samples used, definitions of disability and violence, and methods of data collection. When they pooled the study results there was significant heterogeneity (differences) between individual studies in the proportion of people who experienced violence, making it difficult to give an accurate estimate of the prevalence. Also, many studies failed to include comparison groups, which are needed to compare risk of violence between those with and without disability.
- In studies that did compare people with and without disability, overall there were higher odds of experiencing violence in those with any disability compared with those with none, but analyses by individual type of disability did not consistently give significant associations.
- Regardless of whether or not people have disabilities, they may be unwilling to report violence or abuse, and therefore the rates reported in the reviewed studies may not reflect what happens in reality.
Despite these limitations, this is a valuable attempt to quantify the prevalence and the risk of violence faced by disabled people. Further high-quality research on this important issue is required to understand the magnitude of this problem if strategies are to be developed that can help prevent it.
Links To The Headlines
Mentally ill 'at high risk of being victim of violence'. BBC News, February 28 2012
Links To Science
Hughes K, Bellis MA, Jones L et al. Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies. The Lancet, Early Online Publication February 28 2012