A Twitter discussion has revealed that you don’t need to moisten your toothbrush before using it. Here are five other tips for top-notch oral hygiene
A recent lively Twitter discussion revealed, as these things often do, the existence of a group of utter barbarians: people who do not wet their toothbrush before brushing their teeth. It is almost impossible to believe such people exist, let alone that their method works, but it does. Apparently, it is a matter of preference. “A dry brush increases friction with the bristles and won’t dilute the fluoride in the toothpaste, while a wet toothbrush adds moisture and, for most people, makes the brushing experience more pleasant,” says Damien Walmsley, a scientific adviser for the British Dental Association. “Whatever your preference, what really matters is that teeth should be brushed twice a day, for at least two minutes, with a fluoride toothpaste, including last thing at night.” So, if it is not necessary to add water, what else might we rethink in the dental area?
Don’t brush straight after meals or after certain drinks
“If you eat anything with sugar or carbohydrates in it, the enzymes in the mouth create an acid,” says Derek Richards, a consultant in dental public health and the director of the Centre for Evidence-based Dentistry. This can weaken the surface of the teeth. Sugary drinks or fruit juice “will dissolve the very superficial layers of the teeth; if you brush your teeth straight away, you’re going to start brushing that [surface] away. If you want to brush your teeth straight after fruit, wait 10 minutes or rinse out with water and then brush.”
Spit, don’t rinse
“You shouldn’t rinse your mouth out after you’ve cleaned your teeth because that washes away the fluoride that helps harden your teeth,” says Richards. “Most of the real improvement in the reduction of tooth decay since the 1970s is largely down to toothpaste manufacturers and the fluoride they’ve been putting in.”
A knocked-out tooth can be saved
Sometimes. Rinse it and put it back in the socket immediately, then get to a dentist. If you can’t put it back in or can’t face doing that, put it in cow’s milk – not water – while you seek dental attention. “If it’s put in milk within five minutes, the root’s cells can be preserved for up to an hour,” says Monty Duggal, a former head of paediatric dentistry at the University of Leeds.
Good bacteria might prevent bad breath
In 2013, Scientific American reported that researchers were looking at whether supporting the mouth’s good bacteria could improve bad breath. If this is the case, antibacterial mouthwashes, which kill off all bacteria, could do more harm than good. You can buy oral probiotics, but a review last year of the small number of studies concluded that the data was “deficient”.
Don’t get your teeth whitened by a beauty therapist
It is illegal, although some unscrupulous people offer it. It is possible to buy home whitening kits online, which may conrain unsafe levels of hydrogen peroxide and cause burns or tooth loss. As long as it is carried out by a dentist, teeth whitening is considered safe.
2017 saw more than 21,000 cases and 35 deaths, with large outbreaks in one in four countries, says World Health Organisation
Measles cases have soared across Europe over the last year, with large outbreaks affecting one in four countries, according to the World Health Organisation (WHO) which is concerned by low rates of immunisation against the disease.
WHO Europe says there has been a 400% increase during 2017, with more than 21,000 cases and 35 deaths. That will be a major disappointment following the record low in 2016, when there were just 5,273 cases in Europe.
“Every new person affected by measles in Europe reminds us that unvaccinated children and adults, regardless of where they live, remain at risk of catching the disease and spreading it to others who may not be able to get vaccinated,” said Dr Zsuzsanna Jakab, WHO regional director for Europe. “Over 20,000 cases of measles, and 35 lives lost in 2017 alone, are a tragedy we simply cannot accept.”
Measles can kill or cause long-term damage. One in every thousand children affected develops encephalitis, which is swelling of the brain and can lead to deafness or learning difficulties.
Measles is targeted for elimination around the world, because of the efficacy of the vaccine, but it has been bedevilled by regular outbreaks. WHO said there were large outbreaks last year in 15 of the 53 countries in the European region. Romania was worst affected with 5,562 cases, followed by Italy with 5,006 and Ukraine with 4,767.
Immunisation in those countries has hit a number of problems in recent years. There have been declines in overall routine immunisation coverage, consistently low coverage among some marginalised groups, interruptions in vaccine supply or underperforming disease surveillance systems.
Greece (967), Germany (927), Serbia (702), Tajikistan (649), France (520), the Russian Federation (408), Belgium (369), the United Kingdom (282), Bulgaria (167), Spain (152), Czechia (146) and Switzerland (105) also experienced large outbreaks, many of which were in decline by the close of 2017.
Confidence in the MMR – measles, mumps and rubella – vaccine and in immunisation generally has been an issue in Europe and in the United States following the discredited claims of the researcher Andrew Wakefield, who linked the MMR to the development of autism.
NHS and other key employers face staffing crisis as Home Office refuses visa applications
Britain has hit its cap on visas for skilled non-European workers for an unprecedented third month in a row, deepening the staffing crisis facing the NHS and other key employers.
When the monthly quota was reached in December and January for the first time in seven years immigration lawyers had expected it would prove to be a blip, but they now fear it is turning into a long-term problem.
More than a third of the tier-2 work visas issued by the Home Office go to medical and other staff recruited to work in the NHS. Migration experts expect that among the first group to be turned away will be doctors and other healthcare staff, software developers and scientists.
The next set of quarterly immigration figures will be published on Thursday. They are expected to show increasing evidence of a “Brexodus” over the past year, with an accelerating decline in the numbers of EU nationals coming to work in Britain while increasing numbers return home.
The Home Office sent out hundreds of emails to UK employers and businesses last week telling them that their applications for the certificates of sponsorship required to recruit mostly highly skilled workers from outside the EU had been refused because they did not meet the minimum points score set for the February quota.
The cap on skilled worker numbers operates on an annual quota of 20,700 with a fixed number of spaces available each month. Until last December the monthly quota had only been exceeded in one month since the cap was introduced by Theresa May as home secretary in 2011.
The Home Office confirmed that the minimum salary for a job to qualify for a skilled work visa was normally £30,000, or £20,800 for a graduate recruit. However, in December it was set at £55,000 and in January tier-2 visa applications for jobs paying less than £46,000 a year were refused unless they were PhD-level roles or were for jobs on the official shortage occupation lists.
The points-based immigration system prioritises applicants according to their advertised salary, with the minimum annual pay changing according to the number of applicants above the quota and their points rating. This hits the NHS particularly hard.
Nichola Carter, an immigration specialist at Carter Thomas solicitors, said: “From the information I’m receiving it is starting to look like the threshold for rejection in February could be around the £50k mark. Initially it was thought that December and January were just blips. Now it’s starting to feel like this could be a long-term issue.”
She said employers were increasingly seeking to sponsor skilled workers because they needed certainty in their recruitment plans.
“The government has to step in now and either change the points or the criteria or create exemptions. Calls for NHS workers to be removed have already been made.”
Carter added that she had seen two applications refused for clients last week: a software developer and a designer for a bespoke luxury goods manufacturer.
All jobs offered to skilled workers from outside the EU that are not on the official shortage occupation lists have to be advertised in Britain first for a set period unless the salary will be at least £159,600.
“I know of employers who are now willing to pay £65,000 for a job they were previously offering a salary of £35,000 for just to make sure they get a visa in the next round of allocations,” Carter added.
The immigration law firm Fragomen confirmed that the cap had been reached for the third time. “Since the quota has been exceeded three times consecutively it is highly likely to be exceeded again next month due to the volume of reapplications. Applicants can reapply next month provided the job advertisement is still valid. There is no right of appeal following refusal.”
Danny Mortimer, the chief executive of NHS Employers, has pressed the Home Office to exempt medical staff from the quota, saying NHS organisations were “increasingly concerned at their inability to obtain permits for essential medical colleagues”.
A Home Office spokesperson said: “It is important that our immigration system works in the national interest, ensuring that employers look first to the UK resident labour market before recruiting from overseas.
“The tier 2 visa route is intended to fill gaps in the labour market. When demand exceeds the month’s allocation of tier 2 (general) visas, priority is given to applicants filling a shortage or PhD-level occupations.
“The published shortage lists include a range of medical professionals, including consultants specialising in clinical radiology and emergency medicine, and we estimate that around a third of all tier 2 places go to the NHS.”
A year after the death of his beloved sister, Wise talks about caring for Clare in her last days, and the blog, now a book, they wrote together
It is more than a year since Clare Wise, sister of the actor Greg Wise, died of cancer. She lived just down the street from the West Hampstead house her brother shares with his wife, Emma Thompson, and their daughter, Gaia. As Greg opens his front door and leads the way into his kitchen, one can see, within minutes, why he was such an indispensable carer to his sister during the last weeks of her life. Today, he has organised elevenses with good coffee and patisserie. As an actor, he is routinely cast as a reprobate (Mountbatten in The Crown a debatable exception). In life, he could not be nicer if he tried. And that’s precisely it: he does not appear to be trying – the charm is not fake. When I ask him how he is feeling about Clare’s death now, his eyes fill.
“I’ve had very few days when I’ve not been actively doing something about Clare, be it probate, sorting out her flat, moving furniture – or just the book.” The book is Not That Kind of Love and is a shared effort, written by Clare and Greg. It is fuelled by wisdom and wisecracks, a story of brotherly, and sisterly, love. Clare was 18 months Greg’s senior (he is 51) and worked for the UK Film Council and as vice president of Universal Pictures. She started a blog in 2013 (although the first lump in her breast was found in 2007) and her take on illness drew a crowd – 96,000 hits (by 2015). No wonder: her style is gallant, funny, self-deprecating. It was not until June 2015 that cancer made its terrible comeback into her bones and Greg moved into her flat to take care of her and Grably (her attention-seeking cat). He also took over the blog when she became too sick to write.
Clare’s devotion to her brother (she described him as her “best friend”) is the book’s brightest thread. She relies on him to come with her to hospital appointments knowing he will charm the nurses, tell the right jokes, keep her going. And as to taking on the blog, Greg explains this was a practical decision to protect them from “endless phone calls, emails and texts” and Facebook messages. “It was our way of saying: ‘Please, please, leave us alone. This is what’s happening. Don’t panic.’” Greg’s contribution, which makes up the book’s last third, starts as an update on how Clare is and becomes a meditation on life, on the importance of cherishing the small things – the bark on a silver birch tree in a certain light, matching socks, a slice of cake (he speculates on how differently we would feel were the cake “eternal”). The book ends with Clare’s death at home and is an unedited, un-dolled-up reproduction of their blogs. The writing sometimes has a rough-at-the-edges quality, and this is because Greg insisted it be published as first written: “The thing I felt most violently was: we can’t edit this. This is a real-time piece of writing.” He later discloses, “I’m lucky in that I’ve always been very present” (a good quality in an actor).
I didn’t lose Clare – she died. Passing. Losing. Slipped away… Please. We have to be able to speak death
Now, returning to the question of how he is, his voice wobbles slightly: “When someone goes through a life-limiting disease – and you never know, at the time, how limiting it will be – you have to be careful not to pre-grieve. And yet I couldn’t help grieving for the state my sister was finding herself in. And when she died, I felt, fucking hell, thank God, because this was untenable. Bone cancer is excruciating and this was hard, hard, hard. A part of you is grateful and then you try not to give yourself a hard time for being grateful. I know I’ve not necessarily learned this – and, oh God, I sound like the Dalai Lama – but grief and pain and misery are important. They’re what make us. Life is going to throw shit at you and it’s how you deal with it. It will give you the opportunity to see who you really are.”
The Dalai Lama quip is typical Greg. What is so beguiling is that his seriousness refuses to part company from his talent for seeing absurdity in himself and in life: “It’s essential to be able to have a laugh and Clare was able to do that. Our sense of humour was similar. We loved puns – the groaningly bad sort – and, because of our history, we were able to vibe off each other, to jam, which is a glorious thing.”
I want to know more about Clare. There is a beautiful photograph, on the cover of their book, of Clare and Greg, taken when she was well. She was a generous beauty, with Titianesque red hair, and a teasing smile. She has one hand over Greg’s eyes. What would it have been like had she been with us this morning? “She was open, ebullient, loved socialising. She would have had the croissants at the ready. She’d probably have had a fire on. She might have given me a row for wearing a slightly scruffy top [a crushed, long-sleeved white cotton shirt] but be pleased I’d had a shave. She’d be able to talk well about anything you asked her. She was a ridiculously bright girl [she had a double first in history from Cambridge]. She was cerebral, a huge reader, artistic and wrote beautifully.
“We shared a lot of traits but were very different. It was more than just a boy/girl thing. We were brought up in Northumberland [they lived in Newcastle and had a weekend cottage in the country]. Clare was a city dweller, she couldn’t do countryside.” The cosmopolitan sister was also a virtuoso aunt: “Aunts are fantastically important. On the odd occasions I’ve been asked to be a godparent, I’ve said: ‘I don’t believe in God, but can I please be a rogue uncle? I might be a bit shit for the first years but once they get to 17/18, I’ll take them out and get them pissed.’” Clare was “a rogue aunt” and “an extraordinary travelling companion”. She had a rapport with both their children. Tindy is Greg and Emma Thompson’s adopted son – now 31 – a former child soldier from Rwanda whom they met at a Refugee Council event when he was 16 and who is now a human rights lawyer. In the book, Greg describes Clare as having been “a powerful figure” in Tindy’s life: “She drove him around showing him his new country; introduced him to the sea (where he rushed in fully clothed) and to his first gay couple; got him his first bike; taught him what a ‘holiday’ is; taught him lessons about family.” She was equally close to Gaia (18) who, by the sound of it, could come up with her own version of Travels With My Aunt. “Gaia has been lucky. It is so important to have someone of your parents’ generation who you can go to and say: ‘My dad is such an arse.’ And they can go: ‘He’s always been an arse.’”
In the book, he explains the closeness he and Clare shared as a united front against a “tricky” upbringing. Why tricky? “I would opine that perhaps our parents should never have married (“opine” comes across as a joke choice of verb, suggestive of his caution about getting launched into the subject at all). “It’s difficult because although my parents are dead, I don’t want to upset folk who knew them. Yet anyone who knew the set-up would know it had a reasonably tricky dynamic which made Clare and I work together well, play well and keep our heads down.”
Their parents were architects and Greg initially studied architecture himself and still has plenty of practical flair. Being a carer, he volunteers, is about “minute by minute problem solving” and “trying not to catastrophise”. He goes on: “Generally, if you sit and think – and one of the things you do most as a carer is sit – you can work things through.” He has a sympathetic sensitivity to the potential imbalance between sick person and carer. He maintains that Clare’s “focus on trying to find solutions” helped them both. He would try to “facilitate” whatever she dreamt up. Most importantly, he writes, “It is a hard thing to do, to accept help. It is so much easier to give.”
The impression I am getting is of someone not as different from his description of Clare as he makes out. Like Clare, he is an avid reader and determined to come to grips with what he has been through. In his non-aggressive way, he is a man on a mission. Our “dysfunctional” relationship with death, he suggests, may be about to change: “Almost daily, there are pieces on the radio and television about death and dying. It is the zeitgeist. And it may be because we have never been more anxious about our future, with Brexit, Trump and North Korea. And books like Atul Gawande’s Being Mortal and Paul Kalanithi’s When Breath Becomes Air – about a surgeon dealing with critical illness, and about a surgeon dying – hit the public imagination.” He also raves about Kathryn Mannix’s recently published With the End in Mind. He is convinced that we are frightened of death partly because we don’t “see” it.
Caring for Clare has given him the keenest sense of how much the UK depends upon its carers. “There are 7m carers in the UK and generally with little help and almost no support from government. If they all went: ‘We can’t do this any more,’ and made the state responsible, the NHS would be bankrupt overnight.” Clare was treated in the NHS’s Macmillan Cancer Centre, “a huge, beautiful, bespoke building with extraordinary people in it”. And even though they sometimes had to wait hours before being seen, he remains a passionate champion of the NHS: “We must fight to the death against the NHS being sold off,” he says and wagers: “I’m pretty sure people would accept a ringfenced increase in tax to pay for it.”
What particularly preoccupies him is that “hospitals are not designed for people to get better in. Most people want to die at home but end up dying in hospital. Did you know that most doctors die at home? We have to sort this out as a society. We must demedicalise death. At the point where the palliative care needs to kick in, we have to be professional enough to have that conversation.” He recognises that palliative care has become a fine art: “It is extraordinary.” And he explains: “One of the main conversations you have as a carer is: what is the trade-off between pain management and still being able to be active, if that is what you want to be?”
He briefly speculates, too, about why there is a cancer epidemic at the moment. He does not buy into the idea that it has anything to do with stress: “African subsistence farmers are more stressed than we are,” he says. But he wonders whether certain food manufactures will, one day, be sued for the toxicity of their products – as the tobacco companies once were. And then he adds quietly: “No one is to blame for getting ill.”
It was on 12 September 2015 that Clare described in her blog the moment of being told: “Clare, you have incurable bone cancer…” Her reaction? “WTF, I THINK IS WHAT THE MODERN KIDS SAY…” It was a bombshell that was cruelly timed. She had been about to go with Greg, Emma and Gaia on the “holiday of a lifetime to Greece”. Instead: “I called Greg. Poor Greg – for the second time in his life he had to get a phone call from me saying, ‘Drop everything, it’s cancer.’” What is most striking is that she never had the slightest doubt that Greg would drop everything. There must have been times when being taken for granted was a burden? “Of course – but this was my choice. It was not to do with her. Or maybe it was equally about us both. For there was a contract struck between us that went all the way back to when we were three.” But he then adds the emphatic afterthought that he was not a one-man band.
Clare had a true friend in her sister-in-law. In her blog, she thanks “Em” for her love, strength and “overwhelming generosity and kindness”. And for the laughs. It was Emma who looked after her after her breast cancer surgery. It was Emma who gave herself a new role as hair stylist. On 23 November 2015, Clare writes: “I feel pretty good – have a new trendy pixie haircut (courtesy of my sis-in-law).” It was Emma who took on the not unchallenging task of giving her a shower. Greg’s later efforts used “every bath towel in north London”. Her steadfast qualities were a match for her husband’s. Just before the bone cancer diagnosis, Clare writes: “Em decided she couldn’t stay away with me not being well so gave up her holiday to look after me.” At the same time, she “instituted a very strict and healthy eating regime (also very tasty)”. Clare seemed to relish the side-effects of having a mega-celebrity as sister-in-law. It involved more than going to premieres of films (although this was an undeniable perk). It turned hospital itself into an event. She reports that hospital staff were respectful of Emma until Clare was discharged but that they then “all wanted selfies. As most of the staff there are from the Philippines, I suspect that Em is now more famous than Imelda Marcos.”
Seven months before she died, Emma took Clare to India. “They had a remarkable couple of weeks in an Ayurvedic clinic in Kerala,” Greg says, “Clare was pretty sick. But they had moments when it was just the two of them and they were able to talk.” In Kerala, Clare admitted to Emma that she wished she had let a different sort of love into her life. Greg writes: “She had an extraordinary amount of love in her life – she knew that – but not that kind of love…” And he now recalls: “The day Clare came back from India, I’ve never in my life – or hers – seen her look more beautiful and happy. She was radiating happiness and peace. But then literally the next day, she took herself to bed.” That was, in a sense, the end of her life – although there were to be gruelling clinical trials ahead.
When I ask whether losing Clare taught him any big things, he reacts instantly – not cross but urgent: “I didn’t lose Clare – she died. We’ve got to be clear about that. Passing. Losing. Slipped away. Please… We have to be able to speak death. We don’t know how to talk about death which is odd because we’re all going to die. So: my sister died, she didn’t go to sleep… or pass… or whatever else.” And yet he knows from his own experience that we end up, for all sorts of reasons, skirting around the subject – as his experience of filming The Crown reveals. The first series was made while Clare was ill, and Greg did the job because Mountbatten was a small role. The filming of the second series began two days after Clare’s funeral. “Only the director, producer and first assistant producer knew. I didn’t talk to anyone else.” Protecting yourself? “I was protecting them as well – because people are going to think: oh God, what can I say? This was the first day of a seven-month shoot and everyone was excited. I thought: OK, make sure you know your lines, do them as well as you can.” When he watched the second series, he anxiously scrutinised his face to see whether he had given himself away (he hadn’t).
The big thing death teaches is, he believes, that life is unpredictable. The night before Clare died, Greg had no idea her death was imminent. He quotes from William Goldman’s Adventures in the Screen Trade – a “spectacular” book, published 30 years ago: “Goldman said the most important thing to know in the film business is that no one knows anything. We forget that. We never know what is going to happen.”
Towards the end, Clare couldn’t countenance the idea of anyone other than Greg looking after her, although she admitted to a friend, shortly before she died, that she knew her brother needed “time away”. She never said this to his face, afraid, presumably, of being without him. With hindsight, it seems possible that in registering Greg’s need to get away, she was also registering her own. He does not fail to record her last moments and characteristically assures Clare (he wasn’t lying) that he is sorting everything out:
“I wiped Clare’s face. I held her hand. I kissed her forehead. I told her I loved her. I said how unbelievable we had both been, but I said it was all just getting too fucked-up now. I told her that she didn’t have to worry, that everything was sorted. And I told her she could go now, if she wanted to.”
She died – a minute later – holding his hand.
• Not That Kind of Love by Clare and Greg Wise is published by Quercus (£16.99). To order a copy for £14.44 go to guardianbookshop.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99
Health economist who had a major impact on policy and practice
Alan Maynard, emeritus professor of health economics at the University of York, who has died aged 73, was crucial in the development of his discipline into an international profession. He also had a real impact on policy, not just in the UK.
He was, for example, an originator of the idea that better value for money and better outcomes might be achieved if family doctors were given budgets with which to buy their patients’ care. He was an early and public advocate of the principle that, before the NHS paid for them, drug companies should have to show that their new products were not just clinically effective but cost-effective. That idea resulted in the creation in 1999 of Nice, the National Institute for Health and Care Excellence, a model that other countries have adopted and adapted.
Few would have predicted such an impact for the slightly scrawny kid growing up in postwar Bebington in Cheshire, the son of Edward Maynard, a shoe buyer, and his wife, Hilda (nee McCausland). “He hated school and didn’t really learn to read properly until he was nine,” according to Elizabeth Shanahan, whom Maynard met as a teenager and married in 1968, in one of the few conventional acts of his life. “The world was in revolt,” Liz recalled, “but we got married with lots of bridesmaids and Pyrex casseroles.”
He had scraped into the local grammar school, only to be told bluntly that he would never get to university. But two A-levels took him to Newcastle, initially to do accountancy – “something he also hated” – before a switch to economics took him to the subject that, Liz said, quite simply made him. A second degree at York led to an assistant lectureship at Exeter University alongside Tony Culyer, an equally influential economist.
Back in the 1960s, few economists believed health was a subject fit for their high-minded attention. But Culyer and Maynard, along with Alan Williams, who recruited the pair to York – Maynard became lecturer in economics there in 1971 – are now seen as the founding fathers of health economics in the UK.
Once at York, Maynard created an MSc in the subject and then, in 1983 (the year in which he was appointed professor), established the Centre for Health Economics, which in turn produced “the York diaspora”. More than 750 of its graduates now work in governments, universities, pharmaceutical companies, health services and think tanks around the world. He was an inspirational teacher not just of economists but of medical students, who would find themselves facing questions such as “Is killing people wrong?” Lectures and supervisions were laced with irony, humour and challenge, but also kindness and compassion.
Maynard authored or co-authored more than 500 academic papers, was founding editor in 1992 of what is now the leading journal Health Economics, and in 2015 was awarded the Graham prize – the closest health services research gets to a Nobel prize. However, his role as a great communicator and intellectual agent provocateur was at least as important as his academic work. He wrote countless, often irreverent, media columns, and engaged endlessly with journalists, because, to paraphrase his guide on how to get research translated into action, “you have to find your allies anywhere and everywhere”.
He spent a good chunk of his life hurling squibs of wit and doses of wisdom at the great, the good, and the misguided in the world of healthcare. Politicians were criticised for faith-based rather than evidence-based policy, and for failing to evaluate what they did. The august medical royal colleges were accused of taking taxpayer funded grants but failing to protect patients. The stricture that the NHS has been subject to repeated “re-disorganisation” is almost certainly Maynard’s. And he knew all about that, because, unlike many academics, he was “covered in coal dust” – he was the chair or a director of his local NHS organisations for more than 20 years.
His willingness to throw a match into any passing box of fireworks won him adoring fans. But it also made him enemies. To some he seemed just flippant, a trouble-maker. And he could overdo it. But behind the barbs was almost always a kernel of truth that even those who were wounded could come in time to recognise. Many who mattered most always recognised his value – the Department of Health, the Commons health select committee, the World Bank and the World Health Organisation were just some of those who called in his wisdom as well as his wit.
For behind the irreverence, the alliance building and the provocation was a serious intent – a profound moral belief that it was everyone’s duty to get the best value out of healthcare expenditure. The incentives and vested interests that stood in the way of that had to be challenged. Better incentives had to be found. The success of healthcare had to be measured by its outcomes, not its inputs – and that included the then revolutionary idea that patients themselves, not the just the clinicians, should be asked systematically whether their operation had in fact proved a success. For all that and more, modern healthcare owes him much. Maynard’s manoeuvres were masterful. And indeed a success.
He is survived by Liz and their children, Justin, John, Jane and Samantha, and his older sister, Jean.
• Alan Keith Maynard, health economist, born 15 December 1944; died 2 February 2018
Panelists at a recent Guardian event outlined the technological problems facing the NHS – and pointed the way forward
“It’s archaic, slow, fragile and not streamlined.” So says junior doctor Nadia Masood of the chaotic and fragmented state of NHS information technology.
She described the ritual of learning a whole new set of IT systems every time her rotational training takes her to a different NHS trust. “Rotations happen every three to six months and every time there is a new system to learn. Sometimes I spend hours learning things I just don’t need to know.”
Masood is one of the Justice for Health campaigners, a group of NHS workers who took the health secretary, Jeremy Hunt, to the High Court in 2016 over the new junior doctors’ contract. She was also one of a group of high profile speakers and delegates who earlier this month attended Digital disruption: the role of tech entrepreneurs in improving healthcare – a Guardian event supported by Brother and chaired by the Guardian’s health policy editor, Denis Campbell.
Masood said the NHS has a long way to go until it catches up. “Some hospitals might have 10 different IT systems for different functions, such as prescribing, x-rays and blood tests. Much of the tech is from the 1980s. We still rely on pagers, or are hanging on the end of a telephone. That slows us down and it’s really dangerous.”
Doctors and nurses want to innovate but are hampered by organisations that are digitally fragmented, too scared to embrace the new, or who, where a new development bears fruit, want a piece of the action, said members of the panel.
NHS nurse and entrepreneur Neomi Bennett spent years trying to encourage hospitals to buy her new Neo-slip stocking that helps prevent deep vein thrombosis in patients with circulatory problems.
“The NHS is very comfortable doing things it has always done,” she said.
She added that the procedure for getting Neo-slip accepted by the NHS Supply Chain and bidding for NHS contracts was slow and stifling. “The bidding round is four yearly. I just missed the round when I was trying to get Neo-slip into the NHS so I had to wait another four years – which meant I could do a lot more development on my business plan.”
Bennett says innovators need to be certain about who owns the intellectual property (IP) for any invention – especially where development work has been done in the NHS. “Some trusts want to claim the IP and take it to market, meaning the creator loses control – which can be another disincentive to innovate,” she said.
Panellist Dr Ben Maruthappu was an advisor to current NHS England chief executive, Simon Stevens, and now runs Cera – a homecare provider that uses technology to improve services. He felt that comparisons between the NHS and the seemingly faultless IT systems of big businesses are unfair. He said: “We are not in the food delivery or banking business. Healthcare deals with humans and safety, which is what makes introducing new things a complicated maze. It’s a double-edged sword. Innovation needs to go at a pace that is right for patients and helps liberate entrepreneurs.”
Panellists agreed that innovation must be slower than in the commercial world and proceed in step with greater security to head off potential disasters like the WannaCry cyber attack of May last year, which disabled IT systems across the NHS.
Harpreet Sood, a doctor from University College Hospital (UCH) in London and another former advisor to Stevens, is the associate chief information officer at NHS England. He said serious efforts are being made to streamline healthcare IT and join up the dots between hospital, community and social care. He said: “At UCH we have two dozen systems, but work is underway to develop a single system to coordinate them all which will hopefully be launched by April 2019.”
He added that there are 41 trusts across England developing electronic patient records, which will mean that clinicians across the country can access any patient’s medical record. “Lessons learned from their work will be shared across the NHS so that other trusts don’t need to go through the same cycle over and over again.”
According to Sood, the NHS Innovation Accelerator, which showcases innovations to commissioners and so helps speed uptake, the innovation and technology tariff, which removes financial or procurement barriers for innovative products or technologies, and the Academy of Health Sciences all want to nurture new ideas.
Audience member Jackie Kestenbaum, the director and co-founder of data management company Acadiant Limited, warned: “EPR [Electronic Patient Records] is already out of date. We need to look further.” She gave the audience a Zen-like warning not to be obsessed with current technology.
“It’s like when you point at the moon and your dog just looks at your finger,” she said.
Do you work for the NHS? Please take our survey and tell us about your job. It should only take 10 minutes.
Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views
If you’re looking for a healthcare job or need to recruit staff, visit Guardian Jobs
Faecal transplants have been used in medical settings to tackle superbugs, but following YouTube videos at home is too risky, say researchers
Concerns have been raised about the growing trend for DIY faecal transplants, with experts fearing such attempts could put individuals at an increased risk of HIV and hepatitis as well as conditions ranging from Parkinson’s and multiple sclerosis to obesity and sleep disorders.
The transfer of faeces from one human to another has gained attention as a growing number of studies have suggested links between microbes in the gut and a host of health problems, from autoimmune diseases to anxiety.
Currently, implanting a “healthy” gut microbiome into a recipient is one of the treatments used in medical settings to tackle the superbug Clostridium difficile. But with some claiming the procedure could help a wide range of conditions, a plethora of YouTube videos have sprung up revealing in how to carry out faecal transplants at home.
Experts have raised concerns, stressing that screening is vital to prevent problematic microbes, including those linked to MS and Parkinson’s, from being transferred to recipients – a particular concern for those attempting a DIY procedure.
“Given that we know that these are things that in mice, at least, can be transmitted by the microbiome, it is not cause for panic yet, but it is certainly cause for concern that the same might be true in humans,” said Rob Knight, professor of paediatrics, computer science and engineering at the University of California San Diego, who is presenting his latest work on the microbiome at the meeting of the American Association for the Advancement of Science in Austin this week.
While research has long suggested that obesity could be linked to the microbiome, recent studies have suggested a host of other issues, including sleep disorders, could also be associated with changes in the gut flora. Furthermore, Knight noted that studies have revealed that there are differences in the microbiomes of those with and without conditions such as multiple sclerosis and Parkinson’s disease. “[Very recently] we were able to show that you can transmit aspects of the disease from humans into mice by transmitting the microbiome,” said Knight, although he noted that a particular genetic change was needed in the mice in the case of Parkinson’s.
Currently faecal transplant is used as a treatment for Clostridium difficile infections – the goal being to reseed the gut with “good” microbes. Donors are screened for conditions including infectious diseases and parasites, while those with autoimmune diseases, a history of cancer or gastrointestinal problems are excluded as donors. However Knight stressed that with research throwing up an ever-increasing number of conditions linked to the microbiome, screening is set to become increasingly important. “Tests that look at the whole microbiome profile are still at the research stage,” he said.
The risk of inadvertently transferring either diseases or problematic microbes, he added, are even greater for individuals taking matters into their own hands – a trend Knight said is growing. “It is regrettably something that is increasing in frequency,” he said, noting that in particular those with incurable diseases are often willing to try anything, even if evidence for a procedure is scanty.
The fear that faecal transplants could give recipients more than they bargained for is underscored by a case study from 2015 in which a woman undergoing a faecal transplant for a C. difficile infection ended up becoming obese after receiving a stool sample from her healthy but overweight daughter.
Knight added that his team is currently part of a project that will “Basically capture stool from donors and recipients of faecal transplants on a national scale in the United states so we can get a sense of long term outcomes not just short term outcomes.”
The team is also joining forces with IBM’s Watson to develop a system that can help researchers, patients, reporters and doctors sift and understand the growing body of research on the microbiome. “Human intelligence just can’t keep up with all the literature that is coming out on the microbiome, and so if we can use artificial intelligence to advance our capabilities that will make it really helpful,” Knight said.
Mencap says lack of knowledge may be contributing to avoidable deaths in England each year
A lack of training for health professionals could be contributing to 1,200 avoidable deaths of people with a learning disability in England each year, research has found.
A poll of 506 healthcare professionals for Mencap found 23% had never received training on meeting the needs of patients with a learning disability and 45% thought the lack of training may contribute to avoidable deaths.
The findings were published on Thursday, a week after a coroner condemned “gross failures” in the care of Richard Handley, who had Down’s syndrome and died from constipation.
To prevent such deaths, Mencap, backed by the Royal College of Nursing (RCN), is calling on NHS England and the government to ensure that no health professional can set foot in a hospital without receiving training on learning disability.
The charity’s chief executive, Jan Tregelles, said: “We all need to act to fix this. NHS England has made real efforts to improve care for people with a learning disability but this scandal has been well known over a decade, and families still contact us who believe their loved ones should not have died whilst in hospital care … No family should be left wondering whether or not their loved one could have been saved.”
Research published in 2013 found there were more than three deaths of people with a learning disability every day which could have been prevented by better medical care. Another study, published the same year, found 38% of people with a learning disability died from avoidable causes, compared with 9% of the general population. Despite those figures, Mencap says not enough has been done to address the issue.
To coincide with the launch of its Treat Me Well campaign, Mencap also submitted a number of freedom of information requests to hospitals and English universities on the training they provide.
The responses revealed that 47% of hospitals do not include information on learning disability in their induction training for clinical staff, and 22% of universities were found not to include training on making reasonable adjustments to the care of someone with a learning disability in their undergraduate medicine degree. Making such adjustments is a legal obligation under the Equality Act 2010.
Janet Davies, the RCN chief executive and general secretary, said: “Nursing staff want to be able to deliver the best possible care to every patient, but they need the right education to be able to do that.
“Providers and commissioners of healthcare must offer every member of the nursing team training in how best to meet the needs of people with learning disabilities, and universities must meet their legal obligation to train student nurses in how to provide information for patients with learning disabilities in a way they can understand.”
A Department of Health and Social Care spokesperson said: “Across the NHS health checks, accessible information and staff training are all being put into place to ensure people with learning disabilities are not disadvantaged.”
Findings suggest increased consumption of ultra-processed foods tied to rise in cancers, but scientists say more research is needed
“Ultra-processed” foods, made in factories with ingredients unknown to the domestic kitchen, may be linked to cancer, according to a large and groundbreaking study.
Ultra-processed foods include pot noodles, shelf-stable ready meals, cakes and confectionery which contain long lists of additives, preservatives, flavourings and colourings – as well as often high levels of sugar, fat and salt. They now account for half of all the food bought by families eating at home in the UK, as the Guardian recently revealed.
A team, led by researchers based at the Sorbonne in Paris, looked at the medical records and eating habits of nearly 105,000 adults who are part of the French NutriNet-Santé cohort study, registering their usual intake of 3,300 different food items.
They found that a 10% increase in the amount of ultra-processed foods in the diet was linked to a 12% increase in cancers of some kind. The researchers also looked to see whether there were increases in specific types of cancer and found a rise of 11% in breast cancer, although no significant upturn in colorectal or prostate cancer.
“If confirmed in other populations and settings, these results suggest that the rapidly increasing consumption of ultra-processed foods may drive an increasing burden of cancer in the next decades,” says the paper in the British Medical Journal.
France is one of the few countries that already specifically warns its people against high levels of ultra-processed foods in the diet on “the precautionary principle”, said Mathilde Touvier, lead author of the study. The foods have already been linked to obesity, but the association with cancer is new.
“The results are very strong – very consistent and quite compelling,” she said. “But we have to be cautious. It is the first study. We should not be alarmist. These results need to be confirmed in other prospective studies.”
Ultra-processed food is a definition created by a group of scientists led by Prof Carlos Monteiro in Brazil, a country which also has national dietary guidelines urging they be eaten as little as possible. The classification system, called Nova, puts foods into four groups – raw or minimally processed foods including seeds, fruit, eggs and milk; processed culinary ingredients such as oils and butter; processed foods including bottled vegetables and canned fish and cheeses; and ultra-processed, which are “formulations made mostly or entirely from substances derived from foods and additives”.
Critics of ultra-processed foods say the processing strips out most of the nutrients, but Touvier says they do not believe the low nutritional value of biscuits and sweets and cakes are the cause of the raised cancer risk they saw. “We did a statistical analysis to try to see if the whole association was only due to poor nutritional quality,” she said. “But the results do not depend on that.”
She said they needed to do more research to figure out whether any rise in cancer is down to the high load of sugar, fat and salt or possibly the additives. “We need to understand the mechanism,” she said. “Maybe in the future we will have an idea whether one or two molecules are the problem and not all the ultra-processed foods.”
Her team now have a massive database of all the additives in specific foods, by commercial names and brands. Over the years to come, she said, “we will be able to quantify the chronic exposure [of people] to the food additives”. They will be able to study their effects alone and in combination with other additives, she believes, to find out whether there is “a cocktail effect”.
Other scientists questioned whether it was practical to group foods as ultra-processed. “The term ultra-processed food is difficult to define in terms of food quality, and is not widely used by nutritional scientists,” said Tom Sanders, professor emeritus of nutrition and dietetics at King’s College London. “From a nutritional standpoint, this classification seems arbitrary and based on the premise that food produced industrially has a different nutritional and chemical composition from that produced in the home or by artisans. This is not the case.
“The approach of categorising dietary patterns that depend on industrially processed food in relation to disease risk is novel but probably needs refining before it can be translated into practical dietary advice.”
A spokesman for the Food and Drink Federation said they were proud of the industry’s track record on reformulation “but recognise that obesity and diet-related diseases are a complex and serious issue and more needs to be done. We believe a whole diet and lifestyle approach, which includes consideration of net calorie intake, and not just the role of individual nutrients or ingredients, is the correct way to tackle such issues.
“Processed food should not be demonised – by working closely with our partners throughout the food supply chain, we can use processing positively to ensure all sectors of society have access to safe, affordable food.”
Tam Fry, spokesman for the National Obesity Forum, said: “A lot of research has limitations and the scientists here are honest enough to acknowledge that theirs needs more work to be conclusive. But there is no smoke without fire: we should heed their fears – and read food labels more carefully. Huge quantities of everyday processed food have excessive levels of sugar, fat and salt stuffed in them and it’s all listed on the packaging.”
Actor tells of radical surgery in attempt to end years of chronic pain from debilitating disease
Lena Dunham, the star and creator of the HBO comedy series Girls, has undergone radical surgery to remove her uterus and cervix in an attempt to rid herself of the debilitating disease endometriosis.
The actor, 31, announced her total hysterectomy in an essay in Vogue. She hopes to end the chronic pain she has suffered as well as the “years of complex surgeries measuring in the double digits”.
The decision was a tough one, she said, because she would like children, but she said she felt more positive about the future, hopefully free of a neglected disease that affects an estimated 176 million women worldwide.
“I may have felt choiceless before, but I know I have choices now,” she wrote. “Soon I’ll start exploring whether my ovaries, which remain someplace inside me in that vast cavern of organs and scar tissue, have eggs. Adoption is a thrilling truth I’ll pursue with all my might.”
Endometriosis was for decades a taboo subject – a disease caused by tissue similar to the lining of the womb growing elsewhere, most commonly in the abdomen, ovaries, in the rectovaginal septum, bladder and bowel. The tissue behaves like the lining of the womb, bleeding every month. It can cause such severe and chronic pain that women pass out or are admitted to hospital. Surgery is complex because the tissue grows around organs and fuses them together.
Many women suffer every month for years, unable to attend school, college or their job because of the crippling pain they suffer. Doctors do not always recognise it, assuming it is period pain. If women are referred to a gynaecologist and diagnosed, they may still not get specialist treatment for a condition which is still not well understood.
Dunham has been vocal about her suffering. She has tried every sort of alternative treatment, and lists “pelvic floor therapy, massage therapy, pain therapy, color therapy, acupuncture” and yoga. Neither those nor conventional medical interventions worked long term.
She has been admitted to hospital three times in less than a year. She thought it was all over last April, when she announced she was free of endometriosis after surgery to separate her ovaries from her rectal wall. During her appearance at the Met Gala in New York a few weeks later, however, she was rushed to hospital with complications.
Dunham promptly cancelled her nationwide Lenny IRL tour of six cities. She told fans she was “in the greatest amount of physical pain that I have ever experienced” after doctors discovered more endometriosis.
Experts say the lack of research and funding for a disease that affects one in 10 women of reproductive age is a scandal. “Endometriosis affects women in the prime of their life. It is not a lifestyle disease. It is not a disease you get later in life. It attacks teens, young women when they should be out being active, working, having children, having sex – 50% of them are struggling with sex because it is too painful,” Lone Hummelshoj, who heads the World Endometriosis Research Foundation and the World Endometriosis Society, told a Guardian investigation.
Surgery can end a woman’s suffering if all the rogue tissue is removed. Dunham’s total hysterectomy will only be a cure if none is found elsewhere in her abdomen or bowel.
When she awoke after surgery, Dunham was told her reproductive organs were in a worse state than had been thought. “In addition to endometrial disease, an odd hump-like protrusion and a septum running down the middle, I have retrograde bleeding, aka my period running in reverse so that my stomach is full of blood,” she said. “My ovary has settled in on the muscles around the sacral nerves in my back that allow us to walk. Let’s please not even talk about my uterine lining. The only beautiful detail is that the organ – which is meant to be shaped like a light bulb – was shaped like a heart.”
Dunham is not the only celebrity to have tried to break the silence around endometriosis. Others affected include Emma Bunton, Dolly Parton, Anna Friel, Hilary Mantel, Susan Sarandon and Whoopi Goldberg. After the Guardian’s investigation, the former MP Oona King spoke out about her experiences in the House of Commons.
“When I was stretchered out of the House of Commons in an ambulance, after collapsing on the floor after six hours of earth-shattering pain, one of the attendants whispered, ‘MPs aren’t allowed to die in the palace’. I remember thinking, although I was a supposedly healthy 32-year-old, ‘maybe I am actually dying’,” she wrote. Five days of every month she was incapacitated and unable to give speeches, she said, and the disease made her infertile.