Northamptonshire psychologist Sunil given national voice on health and justice

Northamptonshire psychologist Sunil given national voice on health and justice Having a voice at the highest level, and to champion healthcare for those in the justice system, is part of a new role taken on by a leading psychologist in Northamptonshire.

Dr Sunil Lad, a consultant counselling psychologist at Northamptonshire Healthcare NHS Foundation Trust (NHFT), has just taken on the role of national clinical director for health and justice. Northamptonshire Telegraph

Unborn baby of mother with HIV at centre of court case

Unborn baby of mother with HIV at centre of court case A baby boy whose mother has HIV was given specialist drugs within hours of birth following a High Court case.

The "rare" and "exceptional" ruling was made after Kettering General Hospital NHS Foundation Trust took the matter to court before the child was born.

Doctors feared the mother - unaware of the legal action - would not consent to her baby receiving the anti-retroviral medicine.

The High Court said treatment could go-ahead. BBC Northampton

An NHS in crisis: patients are now waiting longer for almost every type of emergency care

An NHS in crisis: patients are now waiting longer for almost every type of emergency care There’s no doubt that the NHS is deep in crisis. The NHS is facing spiralling waits for emergency and routine care; waves of national strikes; budgets squeezed by inflation; and endless declarations of critical incidents by trust trying to preserve capacity for their sickest patients.

But what does an ’NHS in crisis’ really mean for patients needing emergency care? The unfortunate reality is that patients are likely to face multiple delays on their journey to treatment. The King's Fund

One year on from the backlog recovery plan: what next for NHS waiting lists?

One year on from the backlog recovery plan: what next for NHS waiting lists? One year ago, NHS England published its plan to tackle the backlog of elective care, which had surged following the onset of the pandemic. Since then, as widely expected, waiting lists for NHS treatment in England have continued to grow, increasing by around 1 million between February and November 2022 to just shy of 7.2 million incomplete treatment pathways. In this report, we examine whether the NHS is on track to achieve the challenging ambitions laid out in its backlog recovery plan and present a number of different scenarios for waiting lists over the next two years. Institute for Financial Studies

See also:

• NHS waiting lists will not fall until the summer of 2024 The Daily Mail
• NHS waiting lists in England unlikely to fall in 2023, research suggests The Guardian

Latest NHS reforms will not succeed until Government fixes longstanding problems

Latest NHS reforms will not succeed until Government fixes longstanding problems Major new reform of the NHS will not work until Government addresses multiple chronic issues in the service, says PAC in a report released today. The case has not been made for what improvements Integrated Care Systems (ICSs) will bring to patients, and by when. 

ICSs are the latest attempt to bring NHS and local government services together to join up services and focus on prevention. But in a new report the Committee says the reforms will founder if the major systemic problems in the NHS are not addressed by Government at a national level House of Commons Public Accounts Committee

Major plan to recover urgent and emergency care services

Major plan to recover urgent and emergency care services The NHS and the government will publish a new blueprint today to help recover urgent and emergency care services, reduce waiting times, and improve patient experience.

Frontline capacity will be boosted further thanks to 800 new ambulances, including 100 specialist mental health vehicles, and 5,000 more sustainable hospital beds backed by a £1 billion dedicated fund.

The two-year delivery plan for recovery comes amid record demand for NHS services, with the latest data showing more A&E attendances than ever before, growing numbers of the most serious ambulance call outs, and millions of NHS 111 calls a month over winter. NHS England

Specialised services and system working

Specialised services and system working This briefing outlines NHS England’s changes to specialised commissioning, beginning April 2023, as well as NHS Providers analysis of the benefits and risks that come with greater system leadership.

New strategy to boost NHS access to innovative medical technology

New strategy to boost NHS access to innovative medical technology Patients across the UK are set to benefit from access to safe, effective and innovative equipment and medical devices as part of the first ever medical technology (medtech) strategy published today.

The blueprint for boosting NHS medtech will focus on accelerating access to innovative technologies, such as the latest generation of home dialysis machines that enable patients to manage their own health at home and in their day to day lives. Department of Health and Social Care

Early evaluation of the Children and Young People’s Mental Health Trailblazer programme: a rapid mixed-methods study

Early evaluation of the Children and Young People’s Mental Health Trailblazer programme: a rapid mixed-methods study The Children and Young People’s Mental Health Trailblazer programme is funding the creation of new mental health support teams (MHSTs) to work in schools and further education colleges. MHSTs directly support children and young people with ‘mild to moderate’ mental health problems and work with school and college staff to promote wellbeing for all. A new workforce of education mental health practitioners (EMHPs) is being trained for the teams. This early evaluation of the Trailblazer programme examines the development, implementation and early progress of MHSTs in the programme’s first 25 ‘Trailblazer’ sites. National Institute for Health and Care Research

Retrospective pay talks are 'not right' - Barclay

Retrospective pay talks are 'not right' - Barclay The health secretary said "we should be looking forward" to the pay review body giving its next settlement as health staff in England strike over pay.

Steve Barclay said the government wanted to work "constructively" with unions and was "keen" to get evidence to the independent pay review body "which reflects the pressure the NHS is under and wider context of inflation".

Planned industrial action has suspended in Scotland and Wales following new pay offers, while some nurses and ambulance staff were on strike on Monday. BBC News

See also:

• NHS strike: Re-open pay talks, hospital bosses plead BBC News
• Nurses offer to call off strikes in England if Sunak makes fresh pay offer BBC News
• Why are NHS staff striking and what should patients do? BBC News
• NHS chief: Strikes making hospital bosses restless BBC News
• Steve Barclay warns never-ending NHS strikes are having a terrible impact on patients The Daily Mail
• NHS under fire for hiring branding agency to improve its image amid strikes and waiting list crisis The Daily Mail
• NHS salary: Are UK nurses paid more than those in Europe? The Daily Mail
• How NHS doctor's £110,000 salary is dwarfed by European counterparts The Daily Mail
• Deadlock over NHS pay putting patients in danger, chief nurses warn The Guardian
• Ministers accused of being ‘on strike’ as action by nurses in England continues The Guardian
• Union leader calls Rishi Sunak deluded as NHS pay row escalates The Guardian
• NHS faces worst day of disruption as nurses and ambulance staff in England strike The Guardian
• Ministers ‘punishing’ nurses in England, says union as NHS hit by biggest strike The Guardian
• NHS strikes: Patient safety fears could stop nurses joining further coordinated walkouts The Independent 

HIV testing: Free do-it-at home kit offered in England

HIV testing: Free do-it-at home kit offered in England Free HIV tests that can be done at home are being offered this week to people in England.

It is part of a government drive to improve diagnosis, which dropped off during the Covid pandemic.

The kit is small enough to fit through the letterbox and arrives in plain packaging through the post. BBC News

Stress led to more NHS staff absences than Covid, new figures show

Stress led to more NHS staff absences than Covid, new figures show “Burnout” and stress among doctors, nurses, paramedics and other health staff has cost the NHS in England more than 15m lost working days since March 2020, about 50% more than the days lost to Covid infections and self-isolation, analysis of official figures by the Observer reveals.

NHS sickness figures show that between March 2020, the month of the first Covid lockdown, and last September, 15.4m working days have been lost in the NHS because of stress-related absences, compared with 9.8m days lost from staff who were required to self-isolate or were ill with Covid.

Pfizer’s Susan Rienow: from Covid to fighting the ‘silent pandemic’

Pfizer’s Susan Rienow: from Covid to fighting the ‘silent pandemic’ The pharma giant’s UK chief is adding the company’s voice to scientists’ warnings of the dangers of antibacterial resistance

Pfizer’s president in the UK, Susan Rienow, is lobbying to switch the focus towards early-stage illness to prevent people being hospitalised. “We have a once-in-a-generation opportunity coming out of the pandemic to try to break the cycle of ill health that holds back the economy, the NHS and the health of the population. The key to that is prevention,” she says. “We don’t have enough hospital beds for all the patients who need them.” The Guardian

New blood test is 92% accurate at spotting signs of prostate cancer, study says

New blood test is 92% accurate at spotting signs of prostate cancer, study says A blood test can detect prostate cancer with more than 90 per cent accuracy, a study reveals.

Men who visit their GP with symptoms, such as straining while urinating, have a blood test called a PSA test.

But this is inaccurate, meaning thousands of men are wrongly told they may have prostate cancer and can be sent for a painful biopsy or MRI scan unnecessarily. The Daily Mail

See also: 

• Circulating Chromosome Conformation Signatures Significantly Enhance PSA Positive Predicting Value and Overall Accuracy for Prostate Cancer Detection (open access) Cancers

A short intermission...

We will be taking a small break, but our news service will return on Wednesday the 8th of February.

In the meantime, you can always find us on Twitter @NHFTNHSLibrary

Evaluating a hospital-based youth violence intervention programme

Evaluating a hospital-based youth violence intervention programme Knife crime and other offences among young people are not just an issue for the criminal justice system, they can also affect the health of young people and the health services they use. As part of the RSET project, John Appleby describes the findings of an evaluation of a youth violence intervention programme run by the charity Redthread in collaboration with clinicians at University College London Hospital. Nuffield Trust

Latest winter situation report reveals that the NHS is under more pressure than it was last year

Latest winter situation report reveals that the NHS is under more pressure than it was last year The latest winter situation report shows the continued pressures that NHS leaders and their staff are under. As they get further into the new year, our members say they are continuing to work in difficult conditions as they contend with sustained industrial action which carries risks to patient safety. NHS Confederation

See also:

• Urgent and Emergency Care Daily Situation Reports 2022-23 NHS England
• Rod Stewart calls Sky News offering to pay for NHS hospital scans The Guardian
• NHS figures show ambulance handovers and flu cases improving ITV News
• NHS crisis: 'Over my dead body' - Proposals to make some patients pay for care spark backlash Sky News
• NHS crisis: Patients share their negative and positive experiences Sky News 
• NHS figures: Ambulance delays slowly improving after record waits over Christmas Sky News

UK poverty 2023: the essential guide to understanding poverty in the UK

UK poverty 2023: the essential guide to understanding poverty in the UK This report sets out recent trends in poverty across the UK and how levels of poverty differ between groups of people and regions. It also describes the impact it has on people’s lives, including physical and mental health. Joseph Rowntree Foundation

National flu and COVID-19 surveillance reports published

National flu and COVID-19 surveillance reports published Swab positivity for flu has decreased to 2.8% in week 3, compared to 6.5% in week 2. The highest positivity is seen in those aged 5 to 14 years and in those aged 15 to 44 years at 4.5%.

Hospital admission rates decreased in the last week and are at low activity levels. Intensive care units (ICU) and high dependency units (HDU) hospital admission rates have also decreased, and approached the baseline range of activity levels. UK Health Security Agency

Shopping purchases may help spot ovarian cancer

Shopping purchases may help spot ovarian cancer Tracking what shoppers buy, via loyalty-card data, can help spot those with early signs of cancer, doctors who have been running a study say.

Frequent purchases of over-the-counter painkillers and indigestion tablets revealed a higher risk of ovarian cancer, they found.

Ovarian cancer is often diagnosed late.

There is no reliable screening test and the symptoms, such as bloating, can be vague and confused with other common, harmless conditions. BBC News

See also:

• Association Between Purchase of Over-the-Counter Medications and Ovarian Cancer Diagnosis in the Cancer Loyalty Card Study (CLOCS): Observational Case-Control Study (open access) JMIR Public Health and Surveillance 
• Loyalty cards could be used to spot cancer cases sooner, study suggests The Daily Mail

NHS pay dispute could cause serious long-term harm, says health boss

NHS pay dispute could cause serious long-term harm, says health boss he NHS faces “serious and significant” long-term damage unless the increasingly bitter pay battle between staff and ministers is resolved soon, a senior health service boss has said.

The growing wave of strikes will hamper the NHS’s efforts to tackle the growing chaos in A&E and the 7.2 million-strong backlog of people needing hospital treatment, Sir Julian Hartley said. The Guardian

Doctors issue warning over life-threatening disease as cases spike in children

Doctors issue warning over life-threatening disease as cases spike in children The number of children being treated for Kawasaki disease has risen dramatically by more than double over the last five years.

Experienced mostly in children aged five and below, the NHS has issued a plea for more plasma donations as cases rise.

Latest figures from NHS Blood and Transplant revealed a total of 706 children needing treatment for the disease between 2020-21. The Independent

Blood-based test could detect Alzheimer's disease early, study suggests

Blood-based test could detect Alzheimer's disease early, study suggests A test could detect Alzheimer’s disease three and a half years before it is diagnosed, a study suggests.

The research from the Institute of Psychiatry, Psychology & Neuroscience at King’s College London established a blood-based test that could predict the risk of the condition. The study supports the idea that components in blood can influence the formation of brain cells. The Daily Mail

See also:

• Predicting progression to Alzheimer’s disease with human hippocampal progenitors exposed to serum (open access) Brain
• New blood test could detect Alzheimer’s disease years before diagnosis The Independent

Another £6 BILLION of PPE and Covid tests down the drain: Critics slam £14.9bn of waste

Another £6 BILLION of PPE and Covid tests down the drain: Critics slam £14.9bn of waste Another £6billion of taxpayer cash was 'wasted' on Covid-era equipment last year, it was revealed today.

It means the Department of Health has now lost £14.9billion on over-priced, faulty or unused PPE, tests and drugs since the pandemic began. The Daily Mail

See also:

• Department of Health and Social Care annual report and accounts 2021-22 National Audit Office
• Department of Health wasted £15bn on unused Covid supplies, watchdog finds The Guardian

Norovirus warning in NHS: Health bosses fear rocketing cases of vomiting bug could cripple hospitals

Norovirus warning in NHS: Health bosses fear rocketing cases of vomiting bug could cripple hospitals A post-pandemic surge in norovirus cases could cripple hospitals, health chiefs fear.

Hospital cases of the winter vomiting bug have risen by nearly a tenth in a week — with rates over a third higher than before the pandemic struck.

An average of 371 beds were occupied by patients with tell-tale symptoms of the contagious bug across England last week. For comparison, this is twice as high as levels seen at the same time last year. The Daily Mail

See also: 

• Official Statistics: National norovirus and rotavirus surveillance reports: 2022 to 2023 season UK Health Security Agency

Basis of negotiation: recommendations to improve the NHS pay review process

Basis of negotiation: recommendations to improve the NHS pay review process With the NHS pay review process recently coming in for criticism, Billy Palmer presents an 11-point plan to help make it more fit for purpose. He sets out practical recommendations – for the UK governments, pay review bodies and unions – that would improve the current arrangements. Nuffield Trust

Government Action on Major Conditions and Diseases

Government Action on Major Conditions and Diseases Tackling the major conditions that lead to people spending more years in ill health is a significant opportunity to improve the lives of millions of people. That is why today, I am announcing that, in consultation with NHS England and colleagues across government, my Department will develop and publish a Major Conditions Strategy.

The Strategy will set out a strong and coherent policy agenda that sets out a shift to integrated, whole-person care, building on measures that we have already taken forward through the NHS Long Term Plan. Interventions set out in the Strategy will aim to alleviate pressure on the health system, as well as support the government’s objective to increase healthy life expectancy and reduce ill-health related labour market inactivity. UK Parliament

See also: 

• BPS responds to government plans for a Major Conditions Strategy British Psychological Society
• NHS leaders will welcome government’s recommitment to narrowing the gap in Healthy Life Expectancy by 2030 NHS Confederation
• UK government fall massively short on cross-Government plan promise Mind
• National Voices’ response to the announcement of a Major Conditions Strategy National Voices
• NHS in England will have one strategy for all major conditions, including cancer The BMJ
• Government sets out plans for 'major conditions' health strategy GPonline
• Major Conditions Strategy Announcement Divides Opinion Medscape
• Health secretary announces new Major Conditions Strategy National Health Executive

JCVI advises an autumn COVID-19 vaccine booster

JCVI advises an autumn COVID-19 vaccine booster In its interim advice to government on the coronavirus (COVID-19) vaccination programme for 2023, the Joint Committee on Vaccination and Immunisation (JCVI) has advised that plans should be made for those at higher risk of severe COVID-19 to be offered a booster vaccination this autumn (2023).

The JCVI also advised that for a smaller group of people, such as those who are older and those who are immunosuppressed, an extra booster vaccine dose in the spring should also be planned for. Advice regarding the spring 2023 COVID-19 programme will be provided shortly. UK Health Security Agency

See also:

• Independent report: COVID-19 vaccination programme for 2023: JCVI interim advice, 8 November 2022 Department of health and Social Care
• NHS issues final call to come forward for COVID booster NHS England
• UK health chiefs crank up plans for spring AND autumn Covid vaccine roll-outs The Daily Mail
• JCVI recommends targeted COVID-19 vaccination programme in 2023 GPonline
• Warning of big change to Covid vaccines in UK The Independent

Mental health first aid law proposed in parliament

Mental health first aid law proposed in parliament A new law requiring businesses to offer mental health first aid training has been presented to parliament.

Tory MP Dean Russell told the Commons the move will lead to more people spotting the early signs of mental health issues in the workplace.

Many businesses already offer mental health training to first aiders, but it is not a legal requirement.

Mr Russell told MPs that requiring mental health first aid training in the workplace would save lives. BBC News

Physiotherapists, 'the quiet NHS miracle workers', walk out

Physiotherapists, 'the quiet NHS miracle workers', walk out Thousands of NHS physiotherapists in England have become the latest group to join the ongoing industrial action over pay in the health service.

Physios and their support staff at 30 NHS services - one in seven - are staging a 24-hour walkout on Thursday.

It is the first time members of the Chartered Society of Physiotherapy (CSP) have gone on strike.

As with other striking health staff, physios will continue to provide care in the most urgent cases. BBC News

See also:

• First ever physiotherapy strike over pay takes place in England Chartered Society of Physiotherapy
• Advice for NHS patients affected by physiotherapy strikes Chartered Society of Physiotherapy
• Thousands of NHS physiotherapists go on strike time for first time Evening Standard
• Thousands of NHS physiotherapists to strike over pay The Independent

NHS chief executive says patients need to know hospitals 'are not safe places'

NHS chief executive says patients need to know hospitals 'are not safe places' Nick Hulme, who is in charge of two large NHS trusts, delivered a damning assessment of hospitals at a board meeting of health staff. ITV News

See also:

• In ambulances wait times in England caused record severe harm exposure The Guardian
• The A&E scandal in the NHS has the spotlight. The hidden disaster is the state of long-term care The Guardian
• How well do you understand what's going on in the NHS? Sky News
• NHS in crisis: A day in the life of a GP surgery Sky News

UK facing crisis point in abortion provision, experts say

UK facing crisis point in abortion provision, experts say The UK is facing a “crisis point” in abortion provision, experts say, with rising demand and restricted access to care in many areas putting unprecedented pressure on struggling NHS services.

Healthcare professionals described a “terrifying” state of affairs in which women are travelling hundreds of miles for appointments or waiting several weeks before they are seen. The Guardian

See also:

• Why are women in Britain having to travel hundreds of miles to get an abortion? podcast The Guardian

NHS trust failed in care of baby who died 23 minutes after birth

NHS trust failed in care of baby who died 23 minutes after birth The mother of a baby girl who died in hospital 23 minutes after being born has said she was “failed in the most cruel way” by an NHS Trust that has admitted failings in their care.

The Care Quality Commission (CQC) prosecuted the Nottingham University Hospitals NHS trust after it admitted that its maternity services had not provided safe care and treatment to mother, Sarah Andrews, and her baby, Wynter Andrews. The Guardian

See also:

• NHS Trust admits failings in care of mother and baby who died after 23 minutes ITV News

Hope for more than 150,000 migraine sufferers as NHS approves new wonder drug

Hope for more than 150,000 migraine sufferers as NHS approves new wonder drug A new drug is set to transform the lives of thousands of migraine sufferers after it was approved for use on the NHS.

The National Institute for Health and Care Excellence (NICE) is recommending eptinezumab for around 164,000 adults where at least three previous preventive treatments have failed.

The drug, given as an intravenous infusion every 12 weeks in hospital, has been found to reduce both frequency and severity of migraine attacks. The Daily Mail

See also:

• Eptinezumab for preventing migraine (guideline in development) NICE
• Nice approves new migraine drug for NHS use in England and Wales The Guardian
• New NHS drug will help thousands with migraines The Independent

Women should get ANNUAL breast cancer scans, claims Government's women's health tsar

Women should get ANNUAL breast cancer scans, claims Government's women's health tsar Offering women annual breast cancer checks could save 1,000 lives a year, the women's health tsar has said.

Dame Lesley Regan said the current system of screening women aged 50 to 70 once every three years was 'not based on scientific evidence'.

The UK's breast screening programme has the longest gap between screens in the world.

In the US it is every one or two years and in Europe every two years. The Daily Mail

Cransley Hospice Kettering timeline stone marks 25 years of care at heart of the community and launches celebration year

Cransley Hospice Kettering timeline stone marks 25 years of care at heart of the community and launches celebration year Cransley Hospice has been guaranteed its own place in the history of Kettering after a stone marking the charity’s foundation was unveiled in the town.

To mark the 25th anniversary of the opening of Cransley Hospice based at St Mary’s Hospital, a carved stone has been added to the Kettering Timeline.

Rev Dr John Smith, Cransley Hospice founder, who launched the specialist facility 25 years ago, was special guest at the ceremony. Northamptonshire Telegraph

See also:

• PICTURE SPECIAL - Looking back at the first 25 years of Kettering's Cransley Hospice Northamptonshire Telegraph

Independent health care and the NHS

Independent health care and the NHS Discussion around the role of the independent sector in providing health care often focuses on the ‘privatisation’ of the NHS.

Private providers have always played a role in the NHS, and while there was a small increase in NHS expenditure on independent sector providers following the implementation of the Health and Social Care Act 2012, it has flatlined at a lower level since. The King's Fund

When will the government and national agencies act to ensure that ethnicity coding in health records is fit for purpose?

When will the government and national agencies act to ensure that ethnicity coding in health records is fit for purpose? All governments in recent decades have committed to reducing health inequalities, including among ethnic minority groups. The pandemic’s disproportionate impact on ethnic minority communities highlighted the critical importance of being able to measure health care need, use and outcomes among ethnic minority groups, in order to both mitigate the impact of Covid-19 and address ethnic disparities in health more generally.

The analyses and research that followed illustrated the power of data to inform health strategies designed to protect and improve health. However, the caveat of poor quality of ethnicity coding in health records has been a constant theme, pre-dating the pandemic, requiring analysts to adjust for coding flaws prior to analysis or making do with sub-standard data quality. The King's Fund

See also:

• Understanding consistency of ethnicity data recorded in health-related administrative datasets in England: 2011 to 2021 Office for National Statistics

Can mental health services afford the cost-of-living crisis?

Can mental health services afford the cost-of-living crisis? While the recent extra funding to mental health crisis services is welcomed to help mental health services address the immense pressures the cost-of-living crisis is having on the mental health of England's population, this is short-term thinking. The mental health sector need governmental support to move to preventative approaches. NHS Confederation

The future of pharmacy: manifesto report

The future of pharmacy: manifesto report This report calls for urgent action to deliver on the potential of pharmacy teams and relieve significant funding and workforce pressures. It highlights the need for a new “strategic vision” for pharmacy and highlights opportunities for the pharmacy network to be empowered to deliver even more for patients. However, the manifesto also underlines the very real risk that this opportunity may be lost if significant and ongoing pressures are not addressed. All-Party Pharmacy Group

Care and support reimagined: a national care covenant for England

Care and support reimagined: a national care covenant for England This report sets out three actions to realise a new vision for care and support: rethinking attitudes to care and support; rebalancing roles and responsibilities; and redesigning the social care system. The Commission, which was launched by the Archbishops of Canterbury and York in April 2021, calls for a National Care Covenant, developed through national dialogue, which sets out the roles and responsibilities of government, communities, families and individuals. Key elements of the covenant proposed by the Commission are: investment in communities; a stronger role for the state; a new deal for unpaid carers; and a commitment to our responsibilities as actively engaged citizens. Archbishops’ Commission on Reimagining Care

See also:

• Urgent need to reclaim momentum on social care reform Nuffield Trust

NHS urges women to book a cervical screening as a third don’t take up vital offer

NHS urges women to book a cervical screening as a third don’t take up vital offer The NHS has issued a call for anyone eligible for cervical screening to come forward for a potentially life-saving appointment, with nearly a third, around 4.6 million, not taking up their latest test.

The plea from senior NHS medics comes on the back of the health service sending a record number of invites for cervical screening in the last year, as part of its ambition to eradicate the cancer through a combination of vaccination and early identification.

More than five million invites were sent in the last full year (2021/22) – up by over a tenth (10.5%) on pre-pandemic levels. NHS England

See also:

• Smear tests: GP waiting times putting women off cervical screening BBC News
• 4.6m women in England have missed cervical screening test GPonline

Dreaded Covid-flu twindemic cost NHS this winter

Dreaded Covid-flu twindemic cost NHS this winter Simultaneous big waves of Covid and flu - the 'twindemic' experts warned of as people returned to 'normal' pre-pandemic mixing - cost the NHS this winter, say NHS bosses.

NHS England chief strategy officer Chris Hopson said hospital pressures in England peaked on 29 December.

The workload involved gave hospitals a "significant problem" at the turn of the year, he said.

It was at this point that record-long waits at A&E were seen.

Since then the pressures have begun to ease a little. BBC News

NHS racism shame: One in three Black and minority ethnic staff face discrimination or bullying

NHS racism shame: One in three Black and minority ethnic staff face discrimination or bullying A third of Black and ethnic minority health staff have suffered racism or bullying as the NHS fails to address “systemic” levels of discrimination, The Independent can reveal.

Levels of bullying and harassment of minority workers have not improved in the past five years with almost 30 per cent saying they have been targeted in the past year, compared to 20 per cent of white staff.

Despite being one-quarter of the workforce, minority ethnic staff make up just 10 per cent of the most senior positions, the NHS’s flagship report is set to reveal.

Women in low-income households are less likely to receive the health care they need

Women in low-income households are less likely to receive the health care they need A study of 10,650 females in the UK found those with a combined household income of up to £25,000 per annum are less health literate and are less likely to attend health screenings or vaccination invitations.

In fact, one in 10 have never had health issues such as blood pressure or cervical cancer checked, compared to just five per cent of those in a household earning more than £40,000 per annum. The Independent

Biggest strike day in NHS history will be 'difficult', chief warns

Biggest strike day in NHS history will be 'difficult', chief warns The biggest strike in the history of the NHS will be a “difficult” day, a senior health service leader has warned, as a top emergency doctor described ongoing chaos in A&E departments.

Chris Hopson, chief strategy officer for NHS England, said that combined action on February 6 is a “step change” in the dispute. Evening Standard

See also:

• Striking doctors ‘angry, burned out and demoralised’ - with ‘no light at end of tunnel' The Express
• A&Es ‘haemorrhaging’ nurses as strikes to hit services hard, health chiefs warn The Independent

NHS: What a 12-hour paramedic shift is really like

NHS: What a 12-hour paramedic shift is really like Ambulance response times are the worst on record and the NHS is struggling to cope with a surge in demand this winter.

Sky News joined West Midlands Ambulance Service paramedic Danny Thompson and ambulance technician Dan Fiedler for a 12-hour shift.

Parents still waiting for food vouchers after NHS scheme beset by IT problems

Parents still waiting for food vouchers after NHS scheme beset by IT problems Struggling parents are having to wait more than a year for vouchers to buy healthy food for their children after the relaunch of an NHS scheme was plagued by IT problems.

The Healthy Start scheme, which helps low-income parents and pregnant women pay for fruit, vegetables, milk and formula, has been misfiring since it began the switch away from paper vouchers in October 2021. As it moved from a paper coupon format to a prepaid card system, parents who had been using the old scheme were rejected for the new one without explanation. The Guardian

Massive spike in excess deaths sparks calls for an 'urgent investigation'

Massive spike in excess deaths sparks calls for an 'urgent investigation' MPs have called for an urgent investigation into Britain's soaring death rates as thousands more people than usual are dying each week.

Some 17,381 deaths were registered in England and Wales in the seven days to January 13 – 2,837 above average for the time of year.

This is the highest number of excess deaths since 3,429 in the week to February 12, 2021, when the UK was experiencing its second wave of Covid-19 infections and vaccination had only just begun. The Daily Mail

See also:

• Deaths registered weekly in England and Wales, provisional: week ending 13 January 2023 Office for National Statistics
• The King's Fund responds to the latest ONS mortality data The King's Fund
• Deaths nearly 20% higher than normal amid NHS crisis Evening Standard

Now the NHS eyes up robots to help clear Covid backlogs

Now the NHS eyes up robots to help clear Covid backlogs Robots will have the power to decide patient priority in the NHS after they are employed by the service to help clear the backlog of waiting lists.

Automated calls will be used by the health service to assess people waiting for operations and prioritise their urgency to speed up the handling of referrals.

The plan could see more than 100,000 NHS workers being trained in coding and boy creation to reduce the bureaucratic burden. The Daily Mail

Northampton: Prime minister praises NHS trust's mental health work

Northampton: Prime minister praises NHS trust's mental health work Prime Minister Rishi Sunak has praised an NHS trust's mental health crisis and community services as "trailblazing" on a visit to one of its hospitals.

Mr Sunak was at the Berrywood Hospital in Northampton to announce £150m of funding for UK mental health provision.

He met with representatives from the Northamptonshire Health NHS Foundation Trust (NHFT) to discuss mental health facilities and support.

He said its mental health response hub had put it "ahead of the curve". BBC Northampton

See also:

• Prime Minister visits mental health service in Northamptonshire Northamptonshire Health NHS Foundation Trust
• Prime Minister visits mental health services in Northampton to reveal £150m of funding for projects nationwide Northampton Chronicle and Echo
• Rishi Sunak apologises for not wearing a seatbelt during visit to Northampton hospital Northants Live

Rhetoric about NHS reform is misplaced

Rhetoric about NHS reform is misplaced The NHS is in crisis, and talk of reform is little more than a distraction.

The NHS in England is in crisis. The health service entered the new year – as it did the last one – with several NHS trusts declaring critical incidents, which means they may not be able to provide urgent or safe care. The Health Foundation

Home is at the heart of inclusion health – here's why

Home is at the heart of inclusion health – here's why Jackie Stevens, Associate Director of strategic work programmes, at Hampshire and Isle of Wight Integrated Care System writes about work to make home the heart of inclusion health in one integrated care system. The King's Fund

Follow-up on the IMMDS report and the government’s response

Follow-up on the IMMDS report and the government’s response This report states that ministers must act urgently to enable women and children avoidably harmed by medical intervention to receive compensation and care. The report finds that families have waited too long for redress or compensation because litigation through the courts was the only option open to them. Ministers had rejected an alternative approach recommended by the independent Independent Medicines and Medical Devices Safety (IMMDS) review more than two years ago (‘First do no harm’) for a stand-alone redress agency. House of Commons Health and Social Care Committee

Women being let down by “glacial” Government progress on menopause

Women being let down by “glacial” Government progress on menopause The Government response to the Women and Equalities Committee report on menopause and the workplace is a “missed opportunity to protect vast numbers of talented and experienced women from leaving the workforce.”

Published today, the Government’s response rejects five of the Committee’s recommendations outright, including the recommendation to consult on making menopause a protected characteristic under the Equality Act 2010 and pilot a specific menopause leave policy. House of Commons Women and Equalities Committee

See also:

• 'Menopause leave' trial rejected by ministers BBC News
• Women are being let down by the Government's 'glacial' progress on making workplaces menopause-friendly, MPs warn The Daily Mail
• Government rejection of menopause leave trial could ‘drive women out of work’ The Independent
• Government criticised for rejecting proposals for 'menopause leave' ITV News

Concern over drop in HPV vaccine coverage among secondary school pupils

Concern over drop in HPV vaccine coverage among secondary school pupils The latest UK Health Security Agency (UKHSA) report on the routine adolescent human papillomavirus (HPV) immunisation programme for 2021 to 2022, which is primarily delivered in schools, shows that coverage in year 8 and year 9 pupils is yet to return to pre-pandemic levels.

The HPV vaccine is offered to all 12 to 13 year olds in school years 8 and 9 and follows a 2-dose schedule.

HPV vaccine coverage decreased by 7% in year 8 girls and 8.7% in year 8 boys in 2021 to 2022 when compared to the previous academic year.

Government announces rapid review of inpatient mental health services in England

Government announces rapid review of inpatient mental health services in England The government has announced a rapid review of inpatient mental health services in England.

It follows calls for an examination of patient safety after a Sky News investigation into alleged failures in the care of adolescents at mental health units run by a single provider - the Huntercombe Group, now part of Active Care Group.

Our investigation raised concerns from more than 50 former patients. Sky News

See also:

• Written statement: Mental Health Update: Statement made on 23 January 2023 UK Parliament
• Mind responds to announcement of rapid review of safety in mental health inpatient settings Mind
• Mental health leaders are committed to ensuring the safety and dignity of those who need inpatient care NHS Confederation
• Mental health patient safety review launched in wake of abuse reports Community Care
• Safety risks and failures in mental health settings to be reviewed by Government Evening Standard
• NHS introduces specialist mental-health ambulances to provide better care Evening Standard
• Ministers order ‘rapid review’ into mental health inpatient care in England The Guardian
• Government launches national safety review after scandals (Trust log in required) Health Service Journal
• Government orders urgent review into safety of mental health patients in England The Independent

350,000 patients waited over 12 hours in A&E before getting NHS bed last year

350,000 patients waited over 12 hours in A&E before getting NHS bed last year A record 350,000 patients waited more than 12 hours to be admitted to hospital from A&E last year, according to figures that raise fears about unsafe care as the NHS faces further waves of strike action.

The figures, uncovered in an analysis by the Liberal Democrats, show a steep rise in delays since 2015, when just 1,306 patients waited 12 hours. Senior doctors described the situation as “unbearable” for patients and staff, ahead of a strike in which thousands of ambulance workers will walk out across England and Wales on Monday. The Guardian

Proportion of women in England not screened for cervical cancer at 10-year high

Proportion of women in England not screened for cervical cancer at 10-year high  NHS England data show 4.6m or so women still unscreened or behind with tests, for disease diagnosed in 3,200 annually in UK

Record numbers of women are not being screened for cervical cancer, official figures show, as a leading charity urged ministers to commit to eliminating the disease.

Cervical cancer is the 14th most common cancer among women in the UK. About 3,200 women are diagnosed with it each year, of whom more than a quarter die. The Guardian

League table shame of UK women's healthcare: We languish behind Saudi Arabia in global list

League table shame of UK women's healthcare: We languish behind Saudi Arabia in global list Women's healthcare in the UK is worse than in some countries with poor records on equality, including Saudi Arabia and China, a poll has found.

The UK has ranked lower than most comparable Western countries, including the US, Australia, New Zealand, France and Germany, in the 2021 Hologic Global Women's Health Index published today.

Analysts blamed this on British women struggling to access preventive care, such as cancer screening, as well as diagnosis for causes of pain and mental health support. The Daily Mail

See also: 

• The Hologic Global Women’s Health Index: Pathways to a Healthy Future for Women 2021 Global Report Hologic

Antidepressants can numb enjoyment as well as pain, scientists say

Antidepressants can numb enjoyment as well as pain, scientists say Antidepressants can make patients feel emotionally dull, according to scientists.

One class of antidepressants, selective serotonin reuptake inhibitors (SSRIs), targets serotonin, the ‘feel-good’ chemical that carries messages between nerve cells in the brain.

A SSRI side-effect is ‘blunting’, where patients say they cannot respond with the level of enjoyment they normally would. The Daily Mail

See also:

• Chronic escitalopram in healthy volunteers has specific effects on reinforcement sensitivity: a double-blind, placebo-controlled semi-randomised study (open access) Neuropsychopharmacology
• Scientists explain emotional ‘blunting’ caused by common antidepressants University of Cambridge
• Antidepressants can cause ‘emotional blunting’, study shows The Guardian
• Why antidepressants can blunt both negative and positive emotions New Scientist

Why it's important to see the SAME GP

Why it's important to see the SAME GP Patients at surgeries with a high turnover of GPs are more likely to need emergency hospital treatment than those with steady care, a study has found.

Family doctors with revolving staff were less likely to offer same day appointment or let patients see their preferred doctors.

Experts said the findings should serve as a 'wakeup call' for primary care and were particularly worrying given the number of practices with a high turnover has more than doubled in a decade. The Daily Mail

See also:

• Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study (open access) BMJ Quality and Safety

Northampton councils miss out on levelling-up cash

Northampton councils miss out on levelling-up cash Projects in Northamptonshire have missed out on a share of £4.8bn from the government's latest round of Levelling Up Fund spending.

North and West Northamptonshire councils said they were "disappointed" and were considering proposed projects would be affected.

West Northamptonshire Council's bids included £20m for a leisure centre, cinema, library and new home for health and social services in Weston Favell in Northampton.

A bid of £13m was submitted to restore the stables at Delapré Abbey in the county town, as well as creating a new wellbeing hub and establishing a cancer care centre at Northampton General Hospital. BBC Northampton

See also:

• Northampton projects miss out on Government’s Levelling Up funding - council and opposition ‘disappointed’ Northampton Chronicle and Echo
• Council expresses disappointment over Levelling Up Fund bids West Northamptonshire Council

Mental health services boosted by £150 million government funding

Mental health services boosted by £150 million government funding Anyone experiencing a mental health emergency will benefit from more tailored emergency care and support in the community through specialised mental health ambulances, more crisis services, and improved health-based places of safety.

A £150 million investment up to April 2025 will better support people experiencing – or at risk of experiencing – mental health crises to receive care and support in more appropriate settings outside of A&E, helping to ease pressures facing the NHS. Department of Health and Social Care

Ambulance staff on strike in England and Wales

Ambulance staff on strike in England and Wales Ambulance staff belonging to three unions - GMB, Unison and Unite - are on strike in a dispute over pay.

In line with previous industrial action, life-threatening 999 calls will be attended to, but other emergencies may not be, or could face delays.

The biggest day of industrial action for the NHS in this dispute is set to happen on 6 February, when nurses will walk out too.

Governments say the above-inflation pay rises requested are unaffordable. BBC News

See also:

• NHS England boss: Repeated strikes make workload more challenging BBC News
• Thousands of treatments lost during nurse strikes BBC News
• Ambulance strikes: Unite workers announce new days of walkouts BBC News
• NHS strikes will only end if ministers offer workers a 10 PER CENT pay rise, warns union boss The Daily Mail
• Jeremy Hunt led calls for big pay rise for NHS nurses last summer The Guardian
• NHS leaders voice alarm as 10 more ambulance strikes planned The Guardian
• Health staff strikes making workload ‘more challenging’, says NHS chief The Guardian
• Everything you need to know about the ambulance strikes The Independent
• Tory ministers ‘looking to privatise’ NHS, says union boss The Independent
• As the NHS prepares for its biggest ever walkout, how will strikes impact you? ITV News
• Ambulance workers strike for third time in five weeks as pay and staffing dispute rumbles on Sky News
• Union leader accuses government of 'lying' and suggests it is 'looking to privatise the NHS' Sky News

Mental health: NHS crisis lines failing to answer suicide calls

Mental health: NHS crisis lines failing to answer suicide calls Suicidal patients in England are being put at risk of serious harm, with one in five calls to NHS helplines going unanswered, BBC research shows.

One caller said after repeatedly trying to get through, staff eventually told her to "think happy thoughts".

Coroners have expressed fears over how patients are assessed. One man who died told staff he wanted to end his life, but was not referred for support.

NHS England said crisis lines had seen "record demand". BBC News

Pandemic drinking: Alcohol misuse treatment up 10%

Pandemic drinking: Alcohol misuse treatment up 10% The number of adults treated for alcohol misuse in England climbed 10% in the year to March 2022, fuelled by a rise in drinking during lockdown.

New government data shows this rise pushed the number of people receiving treatment for all types of substance misuse to 289,215, a seven-year high.

And experts say there are many more people struggling with drug or alcohol use who are not receiving treatment. BBC News

Sexual assault and domestic violence ‘going unchecked’ by regulators, NHS staff warn

Sexual assault and domestic violence ‘going unchecked’ by regulators, NHS staff warn Patients and staff are in danger as regulators are accused of poor handling of sexual assault allegations made against doctors and nurses, The Independent has been told.

Campaigners and frontline staff who spoke to The Independent warned that professional regulators are not dealing adequately with allegations of sexual assault, harassment and domestic violence.

£800000 rapid research projects 'to help tackle NHS winter crisis using AI’

£800000 rapid research projects 'to help tackle NHS winter crisis using AI’ Sixteen rapid research projects have been awarded £800,000 to help tackle NHS winter pressures by using existing health data records and artificial intelligence.

These projects – which include helping reduce ambulance wait times and understanding the effects of cold homes on health – have been launched by Health Data Research UK (HDR UK) with funding from the National Institute for Health and Care Research (NIHR). Evening Standard

See also:

• Technology can help the NHS, says AstraZeneca boss BBC News
• £800,000 rapid research projects ‘to help tackle NHS winter crisis using AI’ The Independent
• 'Digital mimics' among 16 projects launched to help NHS with winter pressure Sky News

Long NHS waiting lists cutting chances of pregnancy, fertility chief warns

Long NHS waiting lists cutting chances of pregnancy, fertility chief warns Prospective parents’ chances of having a baby are being affected by long NHS waiting lists for women’s health treatments, the UK’s fertility chief has warned.

Julia Chain, chair of UK fertility regulator the Human Fertilisation and Embryology Authority (HFEA), said delays to women getting diagnoses and treatments for gynaecological issues were preventing them from starting IVF quickly, which meant it was less likely to work. The Guardian

Sajid Javid calls for patients to pay for GP and A&E visits

Sajid Javid calls for patients to pay for GP and A&E visits Patients should be charged for GP appointments and A&E visits, Sajid Javid has said, as he called the present model of the NHS “unsustainable”.

The former health secretary said “extending the contributory principle” should be part of radical reforms to tackle growing waiting times. The Guardian

See also:

• Gordon Brown warns of Tories ‘testing the water’ for two-tier healthcare The Guardian
• Mark my words: this will be the end of the NHS if the Tories have their way | Gordon Brown The Guardian
• Sajid Javid says patients should be charged for GP and A&E visits to ease waits ITV News
• Former health secretary, Sajid Javid, has called for a new NHS funding system ITV News
• Patients should be charged for GP appointments and A&E visits to ease waits, Sajid Javid says Sky News

One in four British dementia patients taking antidepressants but scientists say they are harmful

One in four British dementia patients taking antidepressants but scientists say they are harmful Dementia patients are being put on antidepressants even though the treatment could do more harm than good, experts have warned.

Close to one million Britons are living with the neurological illness, which causes progressively worsening problems with memory and movement – and roughly one in four are prescribed the tablets to combat low mood, agitation and anxiety, which are also common symptoms.

Yet while the drugs are proven to be effective in patients without dementia, a recent series of studies suggest they provide little or no benefit to those with the condition. The Daily Mail

Britons with severe asthma to get 'life-changing' jab that 'turns off' attacks, reducing risk by 70%

Britons with severe asthma to get 'life-changing' jab that 'turns off' attacks, reducing risk by 70% Britons with severe asthma could benefit from a 'life-changing' jab that can reduce the risk of attacks by up to 70 per cent.

The at-home injector pen contains a drug called tezepelumab – which blocks a key chemical that triggers attacks – and is more effective than current treatments.

Insiders have told The Mail on Sunday that the treatment is due to be approved by the National Institute for Health and Care Excellence (NICE) later this year following 'dramatic' trial results.

Number of Northampton hospital A&E patients waiting over 12 hours to be admitted TRIPLES

Number of Northampton hospital A&E patients waiting over 12 hours to be admitted TRIPLES The number of patients waiting in A&E at Northampton General Hospital (NGH) for over 12 hours to be admitted has risen threefold in a year.

Analysis of NHS England data by NationalWorld showed that one in seven patients admitted to hospital through A&E in December endured waits of over 12 hours for a bed once medics decided they needed to be admitted. Northampton Chronicle and Echo

'Patients save up problems for a GP appointment'

'Patients save up problems for a GP appointment' The NHS is under increasing pressure and GPs say they are seeing those issues on a daily basis.

But at a surgery in Moulton, near Northampton, the staff also say they feel privileged to be able to help so many people.

With more than 12,700 patients on its books and more set to join with major housing developments in its catchment area, how the staff dealing with the challenges? BBC Northampton

Emergency healthcare: a national emergency

Emergency healthcare: a national emergency This report includes an action plan, setting out suggestions as to what the Government should do to address the crisis regarding access to emergency care. It finds that, in many cases, patients are attending emergency care services because they have, or feel they have, no alternative. The report concludes that the Government should consider, consult upon, and establish a bold and ambitious new operating model for emergency health care. House of Lords Public Services Committee

People, partnerships and place: How can ICSs turn the rhetoric into reality?

People, partnerships and place: How can ICSs turn the rhetoric into reality? Integrated care systems are now legally responsible for leading the charge on using a localised approach to bring multiple aspects of the health care system closer together, and for working better with social care and other public services. But this is far from a new aspiration - why should it be any different this time? Nuffield Trust hosted a series of roundtables to discuss concerns with stakeholders and experts and understand how to ensure the aims are achieved. This new report consolidates these findings and offers ways forward as the new era gets underway. Nuffield Trust

What our joint vision means for people and communities this winter

What our joint vision means for people and communities this winter Written with the Association of Directors of Adult Social Services and Local Government Association, this briefing sets out a vision for a high-quality and sustainable health and care system. The briefing explores what this might mean in the current context of intense pressures across the system. NHS Confederation

National flu and COVID-19 surveillance reports published

National flu and COVID-19 surveillance reports published Swab positivity for flu has decreased to 6.0% in week 2, compared to 12.2% in week 1. The highest positivity is seen in 0 to 4 year olds at 8.9%.

Hospital admission rates decreased in the last week and are at medium activity levels, approaching the low activity threshold. ICU/HDU hospital admission rates have also decreased, with activity levels returning back to the low activity range. UK Health Security Agency

Ambulance strikes: Unite workers announce 10 new days of walkouts

Ambulance strikes: Unite workers announce 10 new days of walkouts Ten more days of strikes by ambulance workers in England, Wales and Northern Ireland have been announced by the Unite union.

Four of the dates in February and March coincide with walkouts by staff from the GMB union, in a pay dispute.

On 6 February the two unions will be joined by nurses from the GMB in the biggest NHS walkout in this dispute.

A health department spokesman said it is "continuing to have constructive discussions" with unions about pay. BBC News

See also:

• Fury over crippled NHS's February 6 D-Day: Tory MP fears strike will lead to 'unnecessary deaths' The Daily Mail
• NHS ambulance workers announce fresh strike dates as pay row escalates The Guardian
• Ambulance workers announce six more strikes as bitter pay row escalates The Independent
• Ambulance workers from Unite union announce more strikes in coming weeks ITV News

Covid: Half a million people missed out on heart drugs

Covid: Half a million people missed out on heart drugs During the pandemic, nearly half a million people in the UK missed out on starting medication to help prevent heart attacks and strokes, a new study suggests.

The British Heart Foundation (BHF) team looked at prescribing data for the first 18 months after Covid hit.

Some 491,000 people - 27,000 a month - appear to have missed out on blood pressure pills.

And 316,000 did not get treatment to lower their cholesterol. BBC News

See also:

• The impact of the COVID-19 pandemic on cardiovascular disease prevention and management (open access) Nature Medicine
• Analysis reveals there were 800,000 fewer prescriptions for drugs during pandemic The Daily Mail
• Thousands at risk of heart attacks due to Covid disruption, experts warn The Guardian

NHS 'remains under significant pressure' as new hospital figures released

NHS 'remains under significant pressure' as new hospital figures released  More than 14,000 hospital beds in England last week were filled with people who were fit to leave. Meanwhile in Wales, ambulances staff have been on strike. ITV News

See also:

• Urgent and Emergency Care Daily Situation Reports 2022-23 NHS England
• NHS Confederation responds to the latest winter situation report NHS Confederation
• Pressures of NHS's worst-ever winter are EASING The Daily Mail
• Ambulance delays cause ‘severe harm’ to record 6,000 patients a month The Independent
• What the latest NHS data reveals about the pressures hospitals are facing ITV News

‘A contentious place’: the inside story of Tavistock’s NHS gender identity clinic

‘A contentious place’: the inside story of Tavistock’s NHS gender identity clinic Clinicians and young people speak about the pioneering and controversial London facility now facing closure

This is Tavistock and Portman NHS foundation trust on Belsize Lane, a specialist centre for mental health therapies. Within it is the Gender Identity Development Service (GIDS), one of the longest running services for gender-diverse children and young people in the world, founded 33 years ago, but whose work here as a national centre will be wound up within months. The Guardian

Chemo BEFORE bowel cancer surgery slashes chances of disease returning

Chemo BEFORE bowel cancer surgery slashes chances of disease returning Chemotherapy before bowel cancer surgery can slash its chances of returning by more than a quarter, research has found.

The Cancer Research UK funded trial shows that giving chemotherapy ahead of operating for early-stage bowel cancer cuts the chance of the disease coming back by 28 per cent. The Daily Mail

See also:

• Preoperative Chemotherapy for Operable Colon Cancer: Mature Results of an International Randomized Controlled Trial (open access) Journal of Clinical Oncology
• New treatment strategy cuts risk of bowel cancer returning by 28% The Guardian
• Bowel cancer breakthrough as chemotherapy before surgery ‘cuts risk of return’ The Independent