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Rise in children seeking mental health support after terror attacks

The number of children and young people seeking help from mental health services has spiked in the wake of recent terrorist attacks in England, according to the Royal College of Psychiatrists (RCP).

Hospitals across the Manchester region have seen an estimated 10% increase in children seeking help since a bomb ripped through the Manchester Arena on 22 May, killing 22 people, according to the RCP. Mental health experts in Greater Manchester hospitals received hundreds more patients from June to July compared with previous months.

Dr Louise Theodosiou, a consultant child and adolescent psychiatrist at Royal Manchester children’s hospital and a member of the RCP, described the increase as significant and said the terror attack had a “profound impact on the way the children view their city”.

Just a small fraction of those treated had been at the concert; the majority of patients had felt increased anxiety after watching the events on the news. Anxiety and insomnia were the most common complaints, with children worrying about going out or being on public transport after the attacks.

Theodosiou warned the number affected could be significantly greater, with people also seeking support through school or voluntary services and many others yet to come forward for help.

A similar trend has been noticed in London. Dr Jon Goldin, the vice-chair of the child and adolescent psychiatry faculty at RCP, said there had also been anecdotal evidence of “a rise in children seeking mental health services after recent terror attacks”.

“Maybe the rise hasn’t been as much as Manchester [...] but some of those with a predisposition to anxiety have had it heightened by these recent events,” he said.

The increase could be linked to young people’s consumption of media, with children able to access disturbing footage on their smartphones, according to experts. It could also be a positive sign that efforts to reduce the stigma around mental health were having an impact.

Dr Rachel Langley, a clinical psychologist from Southampton children’s hospital’s sleepdisorder service, said: “Technology has a huge amount to answer for in fuelling a rise in children’s sleep problems. It gives young people access to what is going on in the world and also … the blue light of the screens affects melatonin release.”

She added: “There was a 10-year-old boy I saw recently who has anxiety-related insomnia and he has a specific concern about his dad, who works in London, getting caught up in a terror attack.”

In Manchester more young people are expected to seek help in the coming months and years. Theodosiou said: “It has unmasked vulnerabilities that were not there before. It’s fair to say that of the hundreds of children affected only a small fraction would have witnessed the events.”

She added: “If you think of the bomb as being like an influenza epidemic, those most affected by that will be ones with underlying respiratory problems [...] and in the same way the group most affected by the terror attack in the city have been those who are vulnerable to mental health at the beginning.”

Peter Sweeney, another psychiatrist from Royal Manchester children’s hospital, said services needed to plan ahead to manage post-traumatic stress disorder that could hit families and young people.

“We needed to do lots of work for the survivors initially … they got a high level of support at the start. Our concern now is more about young people who may be experiencing anxiety but are not presenting to us, so those who were at the concert but not seriously injured or those who were not at the concert but affected,” he said.

The message to children should be that these attacks should not alter behaviour and that people should get on with their normal lives, said Goldin. “Children should get that message as well as adults. If you have anxious parents saying ‘don’t go to London etc’ then that doesn’t give the most helpful message.

“One message to get across is that it’s important not to feel that, when a child is anxious about a terror attack, they should be taken straight to children’s mental health services. Usually family and a normal support network can really help them. When things are more enduring, for example several weeks after a traumatic experience a child is still struggling with sleep or their mood etc, then you would want CAMHS [child and adolescent mental health services] to get involved.”

  • In the UK, the Samaritans can be contacted on 116 123, and Childline on 0800 1111. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here.

The scandal of big tobacco’s behaviour in the developing world | Letters

I welcome your editorial and related coverage (Stop the spread of the tobacco companies’ poison, 13 July). Tobacco smoking is still the largest single preventable cause of ill-health and death. In the UK the reduction in smoking is one of the great public health success stories. However, it is important that this achievement is not reversed. E-cigarettes should be monitored closely.

Tobacco companies have tremendous financial and political power and, despite the overwhelming medical evidence against cigarettes, they are still able to sell their products. Moreover, certain markets are expanding. Two of the world’s largest tobacco companies are based in the UK. Both continue to perform strongly and are confident about their future performances, especially as markets are growing in lower income countries where there is tremendous potential for profit.

Many of the current strategies used by tobacco companies are not new. More than 30 years ago, Peter Taylor published a seminal book which provided a comprehensive insight into the world of public health politics. The Smoke Ring discusses the ring of political and economic interests surrounding the tobacco industry.
Dr Michael Craig Watson
University of Nottingham

We are concerned, if not surprised, to read the Guardian’s exposé of big tobacco’s use of trade measures to threaten African countries into watering down their efforts to promote public health (Report, 12 July).

A major problem with trade and investment agreements is their chilling effect on public interest legislation: countries that lack the time or resources to defend themselves against a trade dispute hold back from introducing new measures that are good for the public but threaten corporate profits and could provoke a trade challenge. This is particularly problematic where corporations are able to use the investor-state dispute settlement mechanism to sue governments in private tribunals where corporate lawyers act as judges.

For example, after Philip Morris challenged Uruguay and Australia for introducing graphic warnings on cigarette packaging and plain packaging respectively, Costa Rica, Paraguay and New Zealand delayed introducing similar measures. Philip Morris lost that case, but big tobacco is still attempting to bully (particularly low and middle income) countries that attempt to put the health of their citizens before shareholder profit. This has to be stopped.

Countries must be free to pursue independent development and public health strategies. That means having the space to regulate and tax in the public interest without the threat of litigation. We would like to see trade agreements that encourage governments to promote public health objectives, rather than acting as a brake on progress. This requires a fundamental shift in the way that we approach trade deals in the future.
Matthew Bramall Health Poverty Action
Paul Keenlyside Trade Justice Movement
David McCoy Professor of Global Public Health, Queen Mary University London
Dr Penelope Milsom Medact
Deowan Mohee African Tobacco Control Alliance
Alvin Mosioma Tax Justice Network – Africa
Mary Assunta South East Asia Tobacco Control Alliance
Deborah Arnott ASH (UK)
Laurent Huber Action on Smoking and Health (US)
Chiara Bodini and David Sanders People’s Health Movement 
Andreas Wulf Medico International
Jean Blaylock Global Justice Now
Mark Dearn War on Want
Thanguy Nzue Obame People’s Health Movement Gabon

That big tobacco hinders the adoption of anti-smoking legislation is no surprise. Your leader correctly identifies the best route to behavioural change – shareholder pressure – but does not highlight the key channel to achieve this. Big tobacco needs to diversify. This is where shareholder pressure should be applied: to encourage manufacturers and associated leaf merchants to invest in non-harmful products and speed up the process of product diversification. In addition, governments in the south and their development partners should work with manufacturers and merchants to reduce big tobacco’s own addiction to the evil weed.
Dr Martin Prowse
Lund University, Sweden

It is a proud claim we make in this country that 0.7% of our GDP is committed to international development. But efforts to reduce poverty and ill health in developing countries are seriously undermined by the activities of companies such as British American Tobacco.

The tobacco industry has an unrivalled record for dishonesty in trying to prevent its customers becoming aware that there is a 50% chance that they will die from smoking-related causes. It has been a long battle in this country to establish strong measures of tobacco control which have significantly reduced the prevalence of smoking.

In response, the tobacco companies are seeking to get many more people in the developing world addicted to their products. They use the same bogus arguments that have been defeated in the UK to prevent attempts by governments in those countries to prevent this happening. They behave in this way because they make great profits.

The world would be a much better place if such dangerous products were banned. But if this cannot be done by international agreement, then we must at least ensure that we tax them in such a way as to deter such behaviour. The funds raised could also help poorer countries in their fight to establish similar measures of tobacco control to those that are working in the UK.
Chris Rennard
Liberal Democrat, House of Lords

It is deeply unethical that BAT has taken African countries to court to dilute their efforts to protect their populations’ health from tobacco. These countries are still fighting infectious diseases and face a double burden of poor health as a result of non-communicable diseases, with very limited budgets to deal with these.

According to the international covenant on economic, social and cultural rights in the context of business activities (June 2017), these countries are obliged to protect their public’s health, and this includes regulating to restrict marketing and advertising of harmful products such as tobacco.

BAT is headquartered in the UK, so the UK is required to take the necessary steps to prevent human rights violations abroad and it is “contradictory to remain passive where the conduct of an entity may lead to foreseeable harm”.

Moreover, “extraterritorial obligation to protect requires the UK to take steps to prevent and redress infringements of rights that occur outside their territories due to the activities of business entities over which they can exercise control.”

If the UK does not fulfil its extraterritorial responsibility to protect future smokers in Africa, it is possible that it could be liable for damages when many develop cancer, heart disease and strokes. It is incoherent to give British aid for healthcare to these countries while at the same time a UK company is promoting harmful products that diminish people’s right to health.

On a related subject, British MP pension fund, the Parliamentary Contributory Pension Fund (PCPF), invests in BAT and some UK local authority pensions invest large sums in the tobacco industry which many already consider unethical even before the article in the Guardian.
Dr Bernadette O’Hare
University of Malawi and University of St Andrews

Smoking remains a major public health concern, a major contributor to overall mortality and morbidity, to air and water pollution and to physical, economic, social and psychological trauma. However, I must take issue with your allusion to the size of the distance from the developed to the developing world.

The Grenfell tragedy has shone a light on the ills of western societies where people are denied their fundamental rights to safe, clean and adequate housing; where hundreds of thousands are languishing in cramped and dangerous buildings; where homelessness, labour exploitation, knife crimes, racial and religious intolerance and joblessness are increasingly becoming hallmarks of society – and where cover up and deceit are becoming the norm rather than the exception.

To be fair, many developing countries have already recovered from the ills that still plague the developed world. Take a look in the mirror.
Dr Munjed Farid Al Qutob

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Hearing loss could pose greater risk of potential dementia in later life – study

People who experience hearing loss could be at greater risk of memory and thinking problems later in life than those without auditory issues, research suggests.

The study focused on people who were at risk of Alzheimer’s disease, revealing that those who were diagnosed with hearing loss had a higher risk of “mild cognitive impairment” four years later.

“It’s really not mild,” said Clive Ballard, professor of age-related disease at the University of Exeter. “They are in the lowest 5% of cognitive performance and about 50% of those individuals will go on to develop dementia.”

Presented at the Alzheimer’s Association International Conference in London, researchers from the US looked at the memory and thinking skills of 783 cognitively healthy participants in late middle age, more than two-thirds of whom had at least one parent who had been diagnosed with Alzheimer’s disease.

The team carried out a range of cognitive tests on the participants over a four-year period, aimed at probing memory and mental processing, revealing that those who had hearing loss at the start of the study were more than twice as likely to be found to have mild cognitive impairment four years later than those with no auditory problems, once a variety of other risk factors were taken into account.

Taylor Fields, a PhD student at the University of Wisconsin who led the research, said that the findings suggest hearing loss could be an early warning sign that an individual might be at greater risk of future cognitive impairment – but added more research was necessary to unpick the link.

“There is something here and it should be looked into,” she said.

It is not the first study to suggest a link between hearing loss and cognitive troubles – previous research has found that the more severe hearing loss is, the greater the risk of dementia.

But it is not yet clear whether hearing loss is the result of changes linked to dementia, or whether hearing loss itself could contribute to cognitive decline. As a result, it is unclear whether treating hearing loss could mitigate against increased risk.

“Potentially it is something you can do something about, which I think makes it really important to understand better,” said Ballard.

In a separate study, researchers from Wisconsin found a link between thinking and memory difficulties, and changes to the fluency of speech. In 219 late-middle aged participants were assessed at the beginning and end of a two year period. The team found that those with early signs of mild cognitive impairment at the start of the study showed a steeper decline in fluency over the two years than those without.

A further series of studies presented at the conference focused on the link between diet and prowess at memory and thinking tasks. While all differed in the range of participants and the type of diet applied, overall the results suggest that eating healthily was linked to a lower risk of cognitive difficulties, and even a lower risk of dementia.

In one study, carried out by researchers in the US with almost 6,000 participants, scientists found that after taking into account a host of factors including smoking, physical activity, health and socioeconomic status, those who stuck best to a Mediterranean or similar diet over the course of a year were about 35% less likely to have low scores on cognitive tests than those who did not stick to the regime.

While the study does not show that eating badly triggers cognitive problems, and further work is needed to monitor the impact of the diet over time, Claire McEvoy – co-author of the research from the University of California San Francisco – noted that benefits of healthy eating seem to exist on a sliding scale.

“Even moderate adherence to these high quality dietary patterns showed a protective association with cognitive function,” she said.

Sick patients dying ‘unnecessarily’ in NHS because of poor care

Some of the sickest patients that hospitals treat are dying unnecessarily because they receive poor care, blighted by shortages of staff and equipment, a new NHS inquiry has revealed.

A death rate of one in three among inpatients who need emergency help with breathing is already high by international standards, and is getting worse.

The analysis by the National Confidential Enquiry into Patient Outcome and Death of NHS services for the 50,000 patients a year who receive emergency oxygen treatment uncovered a series of major flaws in the care they received. It described its findings as “shocking”.

The growing numbers of patients who receive non-invasive intervention (NIV) – oxygen through a face mask – usually have chronic obstructive pulmonary disease, pneumonia or other conditions which mean they cannot breathe unaided. Despite their lives being at risk, the vast majority receive sub-standard care, according to an in-depth examination of 353 patients during February and March.

“The care of these patients was rated as less than good in four out of five cases. The mortality rate was high: more than one in three patients died,” the inquiry found. “Supervision of care and patient monitoring were commonly inadequate. Case selection for NIV was often inappropriate and treatment was frequently delayed due to a combination of service organisation and a failure to recognise that NIV was needed.” In addition, investigators found from examining case notes that “the quality of medical care provided was often poor. This poor care included both non-ventilator treatment and ventilation management, which were frequently inappropriate”.

Dr Mark Juniper, a co-author of the report and NCEPOD’s lead clinical coordinator for medicine, said the sheer extent of problems he and his colleagues uncovered meant their hard-hitting conclusions were justified.

“This is a major problem which is resulting in unnecessary loss of life. Four out of five patients didn’t receive care that we as doctors would be happy to receive. That’s quite an indictment. That’s shocking because all these patients are at risk of dying.”

NIV in emergency situations is meant to reduce the risk of dying from 20% to 10%. However, NCEPOD found that the death rate among UK patients is 34% – “really troubling”, said Juniper. By contrast, it is only 18% in Spain while France has cut its death rate in recent years from more than 20% to 10%. The UK death rate has been rising steadily since the 30% recorded in 2011.

Two out of five hospitals at some point had been unable to cope with the number of patients who needed NIV because they lacked equipment. “Lack of ventilators is a common problem, even though a basic machine costs about £1,000 to £2,000. When there are too many patients, some end up receiving other medical treatment that’s not as good as ventilation. That will give them a higher risk of dying.”

Other failings researchers found included a lack of nurses, meaning that less than half of hospitals are able to provide the staffing ratio – one nurse to two NIV patients – which guidelines since 2010 have said should be in place. One in five patients who received NIV either did not need it, or needed to be on life support in an intensive care unit instead. In 47% of cases doctors did not convert the patient’s vital signs, such as their temperature, blood pressure and oxygen levels, into an “early warning score” to help dictate the treatment they received. Doctors were often “really poor” at documenting the condition of patients on NIV, probably because of understaffing.

“With these very sick patients the NHS needs to improve a lot – and fast, because lives are at stake,” said Juniper.

Dr Mike Davies, a consultant in respiratory medicine and spokesman for the British Thoracic Society, which represents lung specialists, said the findings had to “act as a stimulus to improve care for NIV patients. We need a concerted effort across the NHS to help reduce avoidable deaths.”

Professor Lesley Regan, who chairs NCEPOD, said the NHS had to learn lessons from the inquiry, given how many patients receive inadequate care. “Many hospitals fail to grasp the size of the problem, as acute NIV usage is all too easily hidden due to poor coding.”

NCEPOD has also found inaccurate coding causes problems among patients who have had a tracheostomy or have sepsis or acute pancreatitis.

She wants hospitals to appoint “local champions” to assess the state of NIV services and ensure that they have the staff and equipment needed.

Revealed: NHS cuts could target heart attack patients in Surrey and Sussex

Patients at risk of a heart attack could be denied vital tests and potentially life-saving operations under NHS plans to make £55m of budget cuts in Surrey and Sussex, the Guardian can reveal.

NHS organisations in Surrey and Sussex are considering restricting the number of patients who have an angiogram or an angioplasty – the insertion of stents to tackle blocked arteries – despite the evidence that both procedures reduce the risk of patients dying.

The disclosure came as senior Tory MP Sarah Wollaston, the chair of the Commons health select committee, urged ministers to scrap the “capped expenditure process” – the secretive cost-cutting regime which the NHS is imposing on 14 areas of England in a bid to save £500m – because it involves “draconian” cuts to services that will hit patient care.

“I don’t think that these extra cuts are reasonable. You can’t justify £500m to the DUP while taking another £500m out of the English NHS,” she told the Guardian.

“The kind of issues that are being discussed [in the 14 areas subject to the CEP] would involve draconian measures that would have an impact on public health and services. [And] I do have concerns about ultimately patient safety.”

Hospitals routinely use an angiogram to assess the health of a patient’s heart. The number of people in the UK undergoing angioplasty has risen eightfold since the early 1990s to almost 100,000 a year, reflecting its growing popularity as a non-invasive alternative to a heart bypass.

Cutting the number of people who have either is one of a range of options which NHS bosses in Surrey and Sussex are considering in order to save £55m more under the CEP by March 2018 than the £106m of “efficiency savings” already agreed.

NHS bodies in Surrey and Sussex privately admit that fewer people will have those procedures as part of their plan to save the £55m by reducing “huge variation” in patients’ chances of having one, depending on which hospital they are treated at and which cardiologist they see. “We have to rationalise cardiac investigations and treatments. There’s variation of 60% to 70% between hospitals. We’re looking into why that is. Who in future won’t get an angiogram? That’ll be up to cardiologists,” said one senior doctor.

In future an unknown number of patients at risk of a heart attack will be monitored by “watchful waiting” rather than given an angiogram or angioplasty, the doctor explained.

Senior NHS sources in the area have disclosed that they are also being forced to consider proposals to:

  • Ration knee arthroscopy operations, cataract removals and tonsillectomies
  • Introduce “lifestyle rationing” so that patients who are obese and smoke will have to lose weight and stop smoking before they can have, for example, a knee replacement to treat their arthritis
  • Shut beds or even whole wards in community hospitals
  • Restrict patients’ access to hearing aids and IVF treatment

“We have been told to leave no stone unturned and think the unthinkable [in the quest to save the £55m],” one local senior NHS figure said, speaking anonymously.

“It’s quite delusional to think we can take out the £106m already planned and now this extra £55m so quickly. But NHS England have told us to do this. The trouble is that, after making lots of efficiency savings in recent years, there is very little fat to take out,” the official added.

NHS organisations in Surrey and Sussex tasked with pursuing the savings drive confirmed that access could be reduced to many different types of care. “We have been looking at all treatments and procedures provided across our area,” they said in a joint statement.

“There is considerable variation in the thresholds and criteria applied before patients are referred for treatment. We want to ensure that referral decisions are based on the latest clinical evidence of what works and are applied consistently, delivering the best value for money for the public and fairness for patients.”

The bodies made clear that they have to contemplate such controversial measures because NHSE and NHSI have told them to save the £55m. Despite already having “ambitious financial plans for 2017-18 … collectively, the plans would overspend by £55m against the financial ‘control total’ that has been set by NHS England and NHS Improvement,” they added.

Heart specialists warned that patients’ health could suffer if decisions about who had either procedure was made on anything other than purely medical grounds. “Any restriction on angiography or angioplasties should be based on clinical criteria and guidelines to ensure no adverse effect on patient care and health,” said Prof Sir Nilesh Samani, the medical director of the British Heart Foundation.

The British Cardiology Society, which represents heart specialists, underlined the importance of both procedures as measures to help save lives. A spokeswoman said: “Cardiovascular disease remains a significant burden to the UK and requires appropriate investigation and management to reduce mortality and morbidity. Despite significant reductions in mortality through medical and invasive treatments both primary and secondary preventive strategies remain important.”

The Royal College of Surgeons said introducing “lifestyle rationing” was “wrong”. A spokesman said: “There is no clinical guidance from NICE, the Royal College of Surgeons and other surgical associations to support restrictions for routine surgery on the basis of whether patients smoke or are overweight.

Saving the £55m this year will prove to be a false economy that costs the NHS more money in the long term, warned Nigel Edwards, chief executive of the Nuffield Trust health thinktank.

“Many of these cutbacks in procedures will only save money in the short term. If they go ahead, this will mean putting off treating patients whose hip and eye conditions will worsen and must be treated eventually. Getting savings out will also require cutting staff,” he said.

This story was amended to correct the statement that a number of cabinet ministers’ seats are in the affected area.