Category Archives: Depressions

Family doctors working ‘beyond safe levels’, says GPs’ leader

As doctors describe dealing with up to 70 patients a day, college warns of risks to public health

Waiting room of GP practice


Patients face longer waits to see a GP, says the Patients Association. Photograph: Alamy


GPs across Britain are working above safe levels because of relentless and unmanageable workloads, leading doctors have warned.

Prof Helen Stokes-Lampard, chairwoman of the Royal College of GPs, said that family doctors were “regularly working way beyond what could be considered safe for patients”, potentially jeopardising their own health and wellbeing.

Her comments were made in response to a survey by GP magazine Pulse. It heard from 900 GPs across the UK and found that each deals with 41 patients a day. The European Union of General Practitioners (UEMO), a leading forum of European family doctors, has said that seeing around 25 patients is safe.

The Pulse poll found that one in five family doctors (20%) deal with 50 daily patient contacts, which include face-to-face and telephone consultations, home visits and e-consultations. Some GPs told Pulse they have 70 contacts a day.

Prof Stokes-Lampard said: “GPs expect to be busy, and we are making more consultations than ever before as we strive to deliver the best possible care to all our patients who need it. But the workload at the moment is relentless and it’s taking its toll.”

One doctor, who reluctantly left a career carrying out 13- to 14-hour days as a partner for a more manageable workload as a salaried GP and 31 to 40 daily contacts, told Pulse: “I felt I was at a risk of making mistakes and causing potential harm to my patients and my career.”

Another spoke of one exceptional “horrendous” Monday where he had 71 contacts. Since then the practice has since increased the number of on-call doctors on Mondays to three.

Prof Stokes-Lampard said the survey backed up what the college has been saying for years – that many GPs are regularly working way beyond what could be considered safe for patients.

It was not necessarily the number of consultations, but the content of those consultations, she added. “Our patients are increasingly presenting with more complex, chronic conditions, many of which require much longer than the standard 10-minute appointment,” she said.

“Our workload needs to be addressed – it has risen at least 16% over the last seven years,” she added. “Yet the share of the overall NHS budget general practice receives is less than it was a decade ago, and our workforce has not risen at pace with demand.”

Dr Richard Vautrey, British Medical Association general practitioners committee chair, said: “We know that an unmanageable and unsafe workload is the primary reason behind doctors leaving general practice, which is leading to serious issues including practices closing to new patients and other surgeries closing entirely. This workload pressure also means GPs are increasingly suffering from burnout and patients are being put at risk of unsafe care.”

He urged the government to work with the BMA to come up with a longterm solution “to ensure the needs of a growing population with increasingly complex conditions can be met safely on the front line”.

Patients’ groups and MPs also expressed concern at the findings. Liz McAnulty, chair of the Patients Association, said: “We have gone past the point where efficiencies can be found, and firmly into territory where GPs’ workloads are unsustainable and where patients face growing waits to access GPs and greater risks to their safety.”

Shadow health secretary Jonathan Ashworth said the Royal College’s warning should serve as an urgent wake-up call to ministers. “The truth is, since 2010 years of severe underfunding of our NHS has left general practice squeezed with tired, overworked and overstretched GPs. We have lost 1,000 GPs in the past year.”

Jo Cox’s sister reveals late MP experienced periods of loneliness

Kim Leadbeater says her older sister felt profound isolation both at university and when she became a mother

Jo Cox


Theresa May has created a minister for loneliness, to focus on an issue Cox worked on. Photograph: BBC/Amos Pictures

The public image projected by the late Labour MP Jo Cox was of a cheerfully confident and outgoing professional, so it is startling to hear her sister describe her as someone who struggled at times with profound loneliness.

She experienced it first when she went to university. “When she went to Cambridge she found herself in a new world, which for a working class northern girl was very intimidating and she found it very difficult,” her younger sister Kim Leadbeater said. “We used to talk on the phone late at night. She missed the safety and the comfort of her family and friends.”

Cox felt very isolated again shortly after the birth of her first child. “When she was a young mum, home alone with a baby she felt very lonely. She would call and say: ‘I just need to have a conversation with an adult,’” Leadbeater said. “When you experience something yourself it stays close to your heart.”

Tackling loneliness was a cause that Cox had begun to work on as an MP, in the 13 months between being elected in May 2015 and being murdered in June 2016, setting up an independent cross-party commission to work on it. After her death, the Jo Cox Foundation made a commitment to continue her work and Theresa May announced this week that she was creating a minister for loneliness to focus on the issue in Cox’s honour.

At a reception at Downing Street to celebrate the plan on Wednesday, the prime minister made a vow directly to Cox’s son Cullin, whose father Brendan previously said had written a song that went “I love my mummy, I will not leave her behind”.

“Cullin, don’t worry – none of us will leave your mummy behind,” May said. “None of us will forget her life, her ideals or what she stood for and all of us will do all that we can to see that in her memory we bring an end to the acceptance of loneliness in our society.”

Brendan Cox and Kim Leadbeater


Brendan Cox, Jo’s husband, and Kim Leadbeater at the Great Get Together event in 2017, which marked the first anniversary of her murder. Photograph: Anthony Devlin/Getty Images

Earlier, Leadbeater had said her sister would have been “elated” at the announcement. “Jo would be over the moon that the issues that she felt passionate about have been taken on. She did so much in the first half of her life and would have achieved so much more in the second half, that there is a responsibility for those of us who loved Jo and knew her to pick up where she left off.”

In an interview shortly before meeting Theresa May and MPs from all parties at a reception to discuss ways of carrying forward Cox’s legacy, Leadbeater said Cox would have found it “hilarious” to see her younger sister forced into the limelight to talk about the campaign. But Leadbeater, who runs a personal training business in Yorkshire, stepped forward to become a spokeswoman for her family in the days after Jo was shot three times outside her constituency office, when she spoke movingly about how her sister “only saw the good in people”. She remains determined to help push on with the work Cox initiated.

As a new MP, meeting people throughout the constituency, Cox was inspired to take up the cause of loneliness because she met so many socially isolated individuals, Leadbeater said. It is striking how many of the profiles of Thomas Mair, the man who shot Cox, refer to him as a “loner” and as “reclusive”. Leadbeater does not believe Mair’s crime could have been averted if he had lived a less solitary life, but she is convinced that isolation has “a very negative impact”. “The best case scenario is that you just feel lonely and the worst case scenario you get drawn towards ways of dealing with that which are incredibly destructive,” she said.

The commission on loneliness set up by Cox warned in December that loneliness can be as harmful to health as smoking 15 cigarettes a day, and stated that more than 9 million people always or often feel lonely.

As part of its work to combat that crisis, the Jo Cox Foundation is announcing a second “great get together”, a weekend of community-building events in the MP’s honour. Last year it was held on the anniversary of her death. This year, it will be held on what would have been her 44th birthday, 22 June.

The idea is to promote community spirit by having lunches and public gatherings, encouraging people to forge new connections, in the spirit of people having “more in common that that which divides us”, a point highlighted in Cox’s maiden parliamentary speech.

The 18 months since her sister’s death have been made more challenging for her family by the string of violent attacks in London and Manchester. “Any time something like that happens we are massively shaken emotionally,” said Leadbeater. It is extremely heartbreaking to see other people go through what we have been through. When you have been through something so horrific you think about the families of the victims; you know what the next 24 hours are like, and what the next weeks and months are like and how life has changes forever – beyond recognition in our case.”

This Christmas was much harder for the family than the first one they spent without her. “Last year we were totally numb and on autopilot,” she said. “This year the reality was more acute.” But Cox’s children, now five and seven, are doing very well. “They are bathed in love and the family has done a fantastic job at keeping them safe,” said Leadbeater. “They have so much of Jo in their personalities – they are extremely positive and resilient, so being around them is wonderful and heartbreaking at the same time.”

Obesity surgery ‘halves risk of death’ compared with lifestyle changes

Latest study lends support to experts who say more operations should be carried out in UK

Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes.


Bariatric surgery reduces the size of the patient’s stomach. It is cost-effective and leads to substantial weight-loss as well as helping to tackle type 2 diabetes. Photograph: Murdo Macleod for the Guardian

Obese patients undergoing stomach-shrinking surgery have half the risk of death in the years that follow compared with those tackling their weight through diet and behaviour alone, new research suggests.

Experts say obesity surgery is cost-effective, leads to substantial weight loss and can help tackle type 2 diabetes. But surgeons say not enough of the stomach-shrinking surgeries are carried out in the UK, with figures currently lagging behind other European countries, including France and Belgium – despite the latter having a smaller population.

“We don’t think this [new study] alone is sufficient to conclude that obese patients should push for bariatric surgery, but this additional information certainly seems to provide additional support,” said Philip Greenland, co-author of the latest study from Northwestern University.

Q&A

Share your experiences of obesity surgery

If you have had stomach-shrinking surgery we would like to hear from you. What was your experience like? Did you find the procedure helpful or not?

You can share your story using our encrypted form here. We will feature some of your contributions in our reporting.

In the new study, one of several on obesity surgery published in the Journal of the American Medical Association, researchers sought to explore whether stomach-shrinking operations, known as bariatric surgery, had a long-term impact on the risk of death among obese individuals, compared with non-surgical approaches to weight loss.

In total, more than 33,500 participants were involved in the study – 8,385 of whom had one of three types of bariatric surgery between 2005 and 2014. The majority of participants had a BMI greater than 35; obesity is defined as a BMI of 30 or higher.

The researchers followed up the participants over the years that followed their surgery until death, or the end of the follow-up period in December 2015, comparing the number of deaths and other metrics with those for obese patients who had not had surgery but were given dietary and behavioural help. Each surgery patient was compared to three who did not have surgery, but had similar characteristics such as age and sex, and were also followed until they too had surgery, died or the study ended.

The results reveal that the death rate during the study was 1.3% for those who had any form of bariatric surgery, while among those who had not had surgery it was 2.3%, although the length of follow-up period varied considerably from patient to patient.

Once other factors including age, sex and related diseases were taken into account, the team found those who did not have stomach-shrinking surgery had just over twice the risk of death compared to those who had, with all three types of surgery linked to lower mortality.

What’s more, the group which had surgery showed a greater reduction in BMI, lower rates of new diabetes diagnoses, improved blood pressure, and a greater proportion of diabetic individuals going into remission.

But the team add that a small proportion of surgery patients required further surgery, while they note the study was observational so cannot prove bariatric surgery itself reduced the risk of death since patients were not randomised, meaning it is possible that those who did not have surgery were in poorer health.

A second, smaller study in the same journal also highlighted benefits of bariatric surgery, comparing diabetes-related markers in obese adults who had lived with a diagnosis of type 2 diabetes for an average of nine years. Participants either received two years of intensive diet, exercise and medical management or, in addition, had bariatric surgery.

The results from 113 participants reveal that complications were more common among those who had had bariatric surgery, but that one year after the study began they had lost more weight on average, with a greater proportion having reached the combined targets for cholesterol, systolic blood pressure and a marker of glucose.

While this proportion fell for both groups after five years – at which point 98 patients were still providing data – those who had had bariatric surgery maintained the edge, with 23% reaching the combined targets, compared to just 4% of those offered lifestyle and medical interventions alone.

Francesco Rubino, professor of metabolic and bariatric surgery at King’s College London, who was not involved in the studies, said misunderstandings and stigma were holding back greater use of such operations in the UK. While Rubino noted that surgery is not for everyone, he added “This is a conversation GPs and doctors should have with patients more often.”

Mexico: 500 years later, scientists discover what killed the Aztecs

Within five years, 15 million people – 80% of the population – were wiped out in an epidemic named ‘cocoliztli’, meaning pestilence

Scientists identified a typhoid-like ‘enteric fever’ for which they found DNA evidence on the teeth of long-dead victims.


Scientists identified a typhoid-like ‘enteric fever’ for which they found DNA evidence on the teeth of long-dead victims. Photograph: FabioIm/Getty Images

In 1545 disaster struck Mexico’s Aztec nation when people started coming down with high fevers, headaches and bleeding from the eyes, mouth and nose. Death generally followed in three or four days.

Within five years as many as 15 million people – an estimated 80% of the population – were wiped out in an epidemic the locals named “cocoliztli”. The word means pestilence in the Aztec Nahuatl language. Its cause, however, has been in questioned for nearly 500 years.

On Monday scientists swept aside smallpox, measles, mumps, and influenza as likely suspects, identifying a typhoid-like “enteric fever” for which they found DNA evidence on the teeth of long-dead victims.

“The 1545-50 cocoliztli was one of many epidemics to affect Mexico after the arrival of Europeans, but was specifically the second of three epidemics that were most devastating and led to the largest number of human losses,” said Ashild Vagene of the University of Tuebingen in Germany.

“The cause of this epidemic has been debated for over a century by historians and now we are able to provide direct evidence through the use of ancient DNA to contribute to a longstanding historical question.”

Vagene co-authored a study published in the science journal Nature Ecology and Evolution.

The outbreak is considered one of the deadliest epidemics in human history, approaching the Black Death bubonic plague that killed 25 million people in western Europe in the 14th century – about half the regional population.

European colonisers spread disease as they ventured into the new world, bringing germs local populations had never encountered and lacked immunity against.

The 1545 cocoliztli pestilence in what is today Mexico and part of Guatemala came just two decades after a smallpox epidemic killed an estimated 5-8 million people in the immediate wake of the Spanish arrival.

A second outbreak from 1576 to 1578 killed half the remaining population.

“In the cities and large towns, big ditches were dug, and from morning to sunset the priests did nothing else but carry the dead bodies and throw them into the ditches,” is how Franciscan historian Fray Juan de Torquemada is cited as chronicling the period.

Even at the time, physicians said the symptoms did not match those of better-known diseases such as measles and malaria.

Scientists now say they have probably unmasked the culprit. Analysing DNA extracted from 29 skeletons buried in a cocoliztli cemetery, they found traces of the salmonella enterica bacterium, of the Paratyphi C variety.

It is known to cause enteric fever, of which typhoid is an example. The Mexican subtype rarely causes human infection today.

Many salmonella strains spread via infected food or water, and may have travelled to Mexico with domesticated animals brought by the Spanish, the research team said.

Salmonella enterica is known to have been present in Europe in the middle ages.

“We tested for all bacterial pathogens and DNA viruses for which genomic data is available,” and salmonella enterica was the only germ detected, said co-author Alexander Herbig, also from Tuebingen University.

It is possible, however, that some pathogens were either undetectable or completely unknown.“We cannot say with certainty that S enterica was the cause of the cocoliztli epidemic,” said team member Kirsten Bos. “We do believe that it should be considered a strong candidate.”

Don’t knock the flu jab – it’s a modern miracle

As the flu season begins to ramp up, so too do the annual complaints about the vaccine

Woman with cold on computer at homeFrome,UK


Varying rates of flu vaccine effectiveness are to be expected, but shouldn’t stop you getting it Photograph: Cultura RM Exclusive/Colin Hawkins/Getty Images/Cultura Exclusive

“The flu jab DOESN’T work, officials admit,” scolded a recent headline from the Daily Mail.

Meanwhile, in the comments under that article, and in shadier regions of the internet, conspiracy theorists are having their usual annual field day: the flu vaccine actually makes people sick; the World Health Organisation is in cahoots with Big Pharma; the vaccine is being deliberately sabotaged by its manufacturers to drum up business for more expensive anti-viral therapies.

Most sensible people understand that our impressive arsenal of vaccines is a modern miracle that prevents vast numbers of premature deaths. Together with improvements in nutrition, sanitation and modern medicine, routine inoculations have lifted us out of the dark ages.

The problem with influenza is that, unlike some other bugs, it’s a tricky shape-shifter. Because of this, the vaccine against it is not nearly as effective as others. For example, a complete course of MMR vaccine is 97% effective at preventing measles; two successive doses of the chicken pox vaccine are about 98% effective; and tetanus toxoid is about 100% effective. What’s more, these impressive figures stay relatively constant year on year.

In contrast, the success of the annual flu vaccine ebbs and flows dramatically, and the healthcare profession is pretty happy when it reaches a modest 40-60% efficacy. Some years it is much worse – as in 2004-05, when its effectiveness was only 10%.

It’s probably no surprise that people think the flu jab is rubbish – especially when the media is delighted to rub failures into the noses of those who work so hard to make it happen. We have become so accustomed to highly effective vaccines that it can be tempting to criticise those that don’t work perfectly. With such high prevention rates, many vaccinated people will feel disappointed when they succumb to the illness. Just as a man who pulled himself out of starvation to become rich might one day frown upon anything but a grand feast, the developed world – from its privileged, 21st century vantage – is happy to talk down a cheap and serviceable preventive measure that improves global morbidity and mortality and reaps significant economic benefit.

And the discontent is rife. In 2014-15, the US Centers for Disease Control issued an early press release warning that some circulating strains had drifted and the vaccine might not be as effective. Traditional media outlets tutted, and antivax interest groups went into meltdown, jeering at the august public health body for this admission, as if anything less than perfection was a humiliation.

In fact, predicting the three or four flu strains that will be included in each year’s vaccination is an astonishing feat of science and surveillance by countless individuals and reference laboratories around the world, on a par with forecasting the precise weather that will occur hour by hour in a month’s time. Every year as the needle slides into my own arm, I give a moment of quiet thanks to these hard-working folk.

Influenza viruses spread from person to person like lightning and also move through various animal reservoirs. In the process, they discard one coat for another, mixing and matching pieces of their genomes with other viruses in an endless game of cat and mouse with the immune systems of the various species they inhabit. Add overpopulated areas and global travel into the picture and what you have is a stochastic, messy and imprecise brew of many thousands of strains, from which only three or four must be plucked.

Once you choose you can’t go back. Because influenza will only grow – painfully slowly – in chicken eggs, it takes half a year to create and stockpile each year’s vaccine. When surveillance picks up crucial shifts after the February deadline, as it did in 2004, it’s far too late to do anything about it.

And let’s unpick the phrase “it didn’t work”. Even the 10% effectiveness rate in 2004-05 wasn’t a complete washout. In the US, as a result of being vaccinated tens of thousands of elderly people did not end up in hospital, and a number of people did not die.

For the price of a cinema ticket, you had a one in ten chance of dodging the disease had you been exposed to. There are lots of gamblers who would be happy to spin the wheel for those odds. I certainly am, having had the flu before and being painfully aware of how long it can wipe you out. Those one in ten who were protected helped to quell infection in others via herd immunity, and the vaccinated people who did get sick likely received some benefit from cross-reacting immunity elicited against the other strains in the vaccine.

There’s been a lot of hype about “Aussie flu” this year, but the offending strain (A H3N2) was around last year and is represented in this year’s vaccine. If the flu season turns out to be as bad in the northern hemisphere as it was in the southern, it won’t be the fault of the vaccine. Instead, we should remember that despite all its imperfections, it’s a remarkable achievement that doesn’t deserve the bad press it perennially suffers. What’s more, one hundred years on from the Spanish flu, which killed 50 million or more people in 1918, it’s comforting to know that we, as a species, have this annual chance to hone our skills of prediction and prevention for when the next pandemic comes.

As a GP, having my heart surgery cancelled gave me a new perspective on NHS underfunding

I am a GP partner in Oxford. I have worked in the NHS in Oxford for 20 years, barring two years in a post in rural Canada. In July 2017, we returned to the UK and a friend of mine, who’s a cardiothoracic anaesthetist, commented on my bounding neck pulses as we were chatting over a beer. A little later that day, I had a listen to my heart and even I, a GP, could hear a loud murmur. I asked one of my colleagues to have a listen, just to check I wasn’t being paranoid. I think he was trying to make me feel better and reassured me: “It’s probably just a flow murmur.”

Nevertheless, I saw my GP that day. With detached, mildly mounting alarm I registered the abnormal findings she discovered. High blood pressure, wide pulse pressure, mild tachycardia and, of course, The Murmur. Her worried expression made me more alarmed than the findings, and I found myself trying to reassure her that everything would be OK.


It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night.

I saw the cardiologist in October and as soon as he mentioned he wanted to get the medical student, I knew I was in for some bad news. He told me I had severe aortic regurgitation, where blood flows in the reverse direction from where it’s supposed to as the heart pumps. He said he’d see me in six months and by that time I would have a new aortic valve. My reaction was silence, followed by expletive-laden surprise, not least as I had had no symptoms at all. Also, doctors never get sick.

It’s funny how that kind of news affects you – for a week or so, I was mentally crossing things off the list of things I could do with the rest of my life, and confronting the possibility that I might not see my daughter grow up.

In December, I was very relieved to get a date for my operation in January 2018 but my urgent surgery was cancelled when I called in at 10am on the day of admission. It’s difficult to describe the sense of loss that I felt. It came as a surprise, even for someone who works in the NHS every day. I really did not know what to do with myself.

As doctors in the NHS, we are trained from an early stage to soak up punishment, not to complain and to always carry on. But with my patient’s brain, I idly wondered how other people might be coping with similarly disorientating news all over the UK. About how they might be thinking how unfair this was, and what would they do now. Lives put on hold, terrible feelings of uncertainty, resignation and finally acceptance. After such news they must love, fear and hate the health service all at the same time. Nevertheless, the NHS is so beloved that it would never cross their minds that the government would have deliberately underfunded it for the last seven years. Some people might think it’s pretty decent of ministers to apologise for all the disruption, and that the government, to its credit, is forward-planning for a winter crisis.

The fact is, of course, that it is not, and that the crisis was entirely avoidable and is down to consistent underfunding. Doctors and the Kings Fund predicted it, even the head of NHS England predicted it. It’s quite difficult to describe the strangled sense of anger as I watched Jeremy Hunt on the news that night. I’m not sure how much more short-notice my surgery cancellation could have been, and yet here was my ultimate boss telling me that this was being done to avoid just such upheaval.

Q&A

Why is the NHS winter crisis so bad in 2017-18?

A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of England’s 153 acute hospital trusts was 98% or more, with the fullest – Walsall healthcare trust – 99.9% occupied.

NHS England admits that the service “has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es”.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. “We are seeing conditions that people have not experienced in their working lives,” says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take – including cancelling tens of thousands of operations and outpatient appointments until at least the end of January – underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.

Read a full Q&A on the NHS winter crisis

I was back to work the next day and I have my game face firmly back on, but I can’t deny it has been disruptive and upsetting. I’m determined not to let any of these developments compromise my patient care and commitment to the NHS. I am sanguine, but waiting hopefully for another appointment. I understand that this situation may well occur again. In that circumstance, I look forward to a time when the apology from my health secretary and prime minister will be replaced by sustained hard investment in the NHS. Platitudes and short-term measures will not save or improve it. And yet, as many commentators have already suggested, perhaps that is this government’s point.

When private meets public sector: the history of a tangled relationship

Interaction between the private and public sectors can be a politically charged process in the UK, not least when the contracts that underpin such a partnership go wrong. Here are some recent examples of cooperation between public bodies and private companies that have caused controversy.

Scottish schools

A private finance contract to build a series of Edinburgh schools became a costly embarrassment after the new buildings were found to be faulty and one partly fell down. A report into the deal found that the contractors had used substandard concrete to build the schools, all of which were considered unsafe and in need of substantial repair. But a review by the council found that the financing behind the Edinburgh Schools Partnership (ESP) was not to blame. ESP is a private finance initiative (PFI), a popular form of funding for projects whereby a company pays the upfront construction cost and is then paid back over time by the government, which effectively pays the constructor to lease the property. However, the review did say there were aspects of the way in which the PFI methodology was implemented that “increased the risk of poor quality design and construction”.

Virgin Health

Private firms scooped almost 70% of the 386 contracts to run clinical health services put out to tender in England during 2016-17. They included the seven highest-value contracts, worth £2.43bn between them, and 13 of the 20 most lucrative tenders. Last year, Virgin Care, owned by Richard Branson sued six clinical trusts after it lost an £82m bid. It secured an out-of-court settlement. It also went on to win £1bn worth of contracts.

London Underground PPI

Bob Kiley, tube boss in the early 2000s


Bob Kiley, tube boss in the early 2000s, described the PPP financing model for transport improvements in London as ‘fatally flawed’. Photograph: Channel 4

A series of public-private partnerships (PPPs) were signed by the last Labour government in 2002 and 2003 to upgrade and carry out maintenance on London’s tube network. Described at the time by then tube boss Bob Kiley as “fatally flawed”, by 2010 the process had unravelled. In exchange for carrying out complex work on an ailing network, the businesses behind the contracts would receive a monthly payment that would increase or decrease depending on whether they hit targets for measures such as train cleanliness and reliability of services. The process became mired in endless rows over costs; the biggest contractor, Metronet, eventually went bust and the other, Tube Lines, was bought out.

East coast rail

For the second time in a decade, the secretary of state for transport has been forced to bail out a private rail company running the vital east coast mainline. In 2009, the then Labour government took the line under public control after its private operator, National Express, couldn’t pay out the £1.4bn promised under the contract. The previous holder of the franchise, GNER, had already been stripped of the route after its US parent firm was struck by financial troubles. Last year, the government waived the majority of payments due under Stagecoach’s £3.3bn contract to run the London to Edinburgh route. Whenever the merits of rail privatisation are debated, the east coast line is a key argument for those in favour of nationalisation.

I love my job as a prison psychologist. But it’s time I was paid fairly

Over the past 10 years I have seen a lot. Being a prison forensic psychologist is not a job for the faint hearted, but I love it.

As a forensic psychologist I am closely involved in assessing and treating criminal behaviour. I frequently go to parole board hearings and advise on whether violent and sexual offenders are suitable for release. It took an undergraduate degree, a masters and an ongoing professional development diploma to get here. It is a huge responsibility – and yet my salary is £29,000. I take home just £1,500 a month.

My colleagues and I feel undervalued. It is taken for granted that we will continue to work for the public sector out of love and loyalty. But the sector cannot rely on employees’ goodwill alone forever.

The government’s austerity measures have impacted me in other ways too. I have been assaulted at work because there aren’t enough officers around to ensure civilian staff are protected in the work they do. They are similarly undervalued, underpaid and overstretched.

My colleagues and I have been stretched further and further, so we are now providing the bare bones – and I do sometimes fear for my safety.

We are all expected to carry on, regardless of the threats and the struggle to make ends meet, because of the love of the job. That was once enough – but now I want to start a family, and that requires more income.

Advising on whether prisoners are suitable for release can take weeks. Weeks of interviewing the prisoner, reading their file information, reviewing their behaviour on the wing, checking their correspondence. Weeks of speaking to the staff who work with them, liaising with the security department and the probation service.

And then come the big decisions about whether prisoners need more treatment; whether they can go to a lower category prison without risk of trying to escape; or whether they can be safely released. I have to ask myself if I am confident they can return to society without harming someone else. And if they did, how would I live with myself knowing I had advised the parole board that I thought they were ready?

I have seen profound changes in prisoners I’ve worked with over time. I’m most proud of the work I did with a man with learning disabilities who had previously reoffended within a week each time he was released. The treatment he’d had didn’t work because he simply didn’t understand; it was too complicated for him. I worked with him over months, adapting the work by using different techniques, like drawing and role play.

I took the time to understand why he’d committed his crimes and what his learning needs were. I worked with his family so they could continue to support him. I helped him gain supported accommodation. He was released again and has stayed offence-free. That was five years ago. He still sends me letters because he says I made a difference in his life.

I take so much pride in my job and want to continue doing it, because I know it allows me to make a difference to society as a whole. As a previous victim of violent crime, my greatest motivation is to ensure that future crimes are prevented and people don’t experience what I went through.

But I’m not going to lie: sometimes it is hard to remain motivated when I have such little income coming in. I look around me and see friends who work as personal assistants to businesspeople earning more than me. The low pay makes me question whether I have taken the right route.

I have seen colleagues leave for private practices. They are working fewer hours for more pay. But if everyone does that, who will be left to do this work for the public sector?

I feel passionately about the work I do and feel it deserves fair pay. I’m not asking for the earth. I’m not asking for a massive wage. I’m just asking for a fair reflection of the work I do, the commitment I show – and the responsibility I have.

This series aims to give a voice to the staff behind the public services that are hit by mounting cuts and rising demand, and so often denigrated by the press, politicians and public. If you would like to write an article for the series, contact kirstie.brewer@theguardian.com

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Shifting care closer to home will ease pressure on hospitals | Ewan King

New year is associated with hope and optimism. But for the NHS, the headlines tell a different story: hospitals at full capacity. As you might expect, these articles focus on what is going wrong: headlines such as “NHS in crisis”, stories of beds in corridors and stressed-out nurses. Clearly these problems are real, but focusing only on hospitals won’t solve the problem. We need to think more broadly if we are to find lasting solutions; we must think about prevention, and how far it is embedded in local systems.

For some time, health and care reforms have been about shifting care closer to home. The programme of vanguards and sustainability and transformation plans was intended to herald a greater focus on prevention and self-care to reduce pressure on hospitals. There is some evidence that these reforms are working: Hertfordshire’s prevention-focused Better Care for Care Home Residents Vanguard, for instance, led to a 45% reduction in hospital admissions and A&E attendances between April 2015 and May last year.

But we are not yet able to see the scale of change necessary to make a significant dent in demand across England and beyond, because of financial pressures, which make it difficult for organisations and commissioners to fund new, innovative services; inward-looking leadership teams focused on short-term goals and local evidence and solutions; a lack of integration across health and social care and housing; and outdated performance management and contracting systems.

A seismic shift – at the level needed – is not straightforward to deliver. As Nesta, Shared Lives and the Social Care Institute for Excellence (Scie) argue in a new report on innovation, we know a lot about what works to support independence in ways that reduce demand for urgent care, but less about how to extend the benefits to more people. As the report concludes: “New and better ways of delivering relationship-based care are needed, and already exist, but are inconsistently implemented or poorly scaled.”

So what can national policymakers and local health and care leaders do differently? First, we need to restate the case for preventive, community-based care and, as part of this, more clearly articulate how it will make a difference to people’s lives. For example, in our report we describe a place in the near future where people are supported to maintain their independence, improving their wellbeing at reduced cost to the NHS. What if you have a long-term condition such as chronic obstructive pulmonary disease; are you able to join a Breathe Easy peer support group to help you manage the condition?

We also talk about North Yorkshire, where an innovation fund has been used to fund initiatives reducing isolation, preventing falls and supporting people to stay at home when they want to. Local care and support providers say this has helped them to build their networks, and they are now working in partnership with more local services.

Second, we need collective local leadership focused on keeping people well and better supported at home, underpinned by a strong commitment to integrated commissioning and to changing funding flows to support more community-based care.

A hospital trust chief executive recently told me that investment away from beds and A&E services would support far better preventive approaches – but there has to be a system-wide strategy for all to lead and support if bed pressures arise.

Third, we need to make better use of the evidence we have, making a stronger case for investment in preventive care. In Scie’s prevention library, we have a mass of evidence-based examples of community-led care and support that helps to reduce demand for hospital care. Age UK’s personalised integration approach in North Kent is a model of holistic support targeted at older people with long-term conditions. It has led to a 26% reduction in non-elective hospital admissions. Commissioners need to use these examples to argue for spending more on preventive models of care and support.

Carrying on as we are is unlikely to succeed; we are firefighting in the face of growing demand in hospitals without always considering what wider changes are needed to prevent this growth. The social care green paper, to be published in the summer, provides a good opportunity for setting out plans for a more preventive, person-centred, health and care system, but there is nothing to stop leaders being more ambitious about prevention right now.

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

Shifting care closer to home will ease pressure on hospitals | Ewan King

New year is associated with hope and optimism. But for the NHS, the headlines tell a different story: hospitals at full capacity. As you might expect, these articles focus on what is going wrong: headlines such as “NHS in crisis”, stories of beds in corridors and stressed-out nurses. Clearly these problems are real, but focusing only on hospitals won’t solve the problem. We need to think more broadly if we are to find lasting solutions; we must think about prevention, and how far it is embedded in local systems.

For some time, health and care reforms have been about shifting care closer to home. The programme of vanguards and sustainability and transformation plans was intended to herald a greater focus on prevention and self-care to reduce pressure on hospitals. There is some evidence that these reforms are working: Hertfordshire’s prevention-focused Better Care for Care Home Residents Vanguard, for instance, led to a 45% reduction in hospital admissions and A&E attendances between April 2015 and May last year.

But we are not yet able to see the scale of change necessary to make a significant dent in demand across England and beyond, because of financial pressures, which make it difficult for organisations and commissioners to fund new, innovative services; inward-looking leadership teams focused on short-term goals and local evidence and solutions; a lack of integration across health and social care and housing; and outdated performance management and contracting systems.

A seismic shift – at the level needed – is not straightforward to deliver. As Nesta, Shared Lives and the Social Care Institute for Excellence (Scie) argue in a new report on innovation, we know a lot about what works to support independence in ways that reduce demand for urgent care, but less about how to extend the benefits to more people. As the report concludes: “New and better ways of delivering relationship-based care are needed, and already exist, but are inconsistently implemented or poorly scaled.”

So what can national policymakers and local health and care leaders do differently? First, we need to restate the case for preventive, community-based care and, as part of this, more clearly articulate how it will make a difference to people’s lives. For example, in our report we describe a place in the near future where people are supported to maintain their independence, improving their wellbeing at reduced cost to the NHS. What if you have a long-term condition such as chronic obstructive pulmonary disease; are you able to join a Breathe Easy peer support group to help you manage the condition?

We also talk about North Yorkshire, where an innovation fund has been used to fund initiatives reducing isolation, preventing falls and supporting people to stay at home when they want to. Local care and support providers say this has helped them to build their networks, and they are now working in partnership with more local services.

Second, we need collective local leadership focused on keeping people well and better supported at home, underpinned by a strong commitment to integrated commissioning and to changing funding flows to support more community-based care.

A hospital trust chief executive recently told me that investment away from beds and A&E services would support far better preventive approaches – but there has to be a system-wide strategy for all to lead and support if bed pressures arise.

Third, we need to make better use of the evidence we have, making a stronger case for investment in preventive care. In Scie’s prevention library, we have a mass of evidence-based examples of community-led care and support that helps to reduce demand for hospital care. Age UK’s personalised integration approach in North Kent is a model of holistic support targeted at older people with long-term conditions. It has led to a 26% reduction in non-elective hospital admissions. Commissioners need to use these examples to argue for spending more on preventive models of care and support.

Carrying on as we are is unlikely to succeed; we are firefighting in the face of growing demand in hospitals without always considering what wider changes are needed to prevent this growth. The social care green paper, to be published in the summer, provides a good opportunity for setting out plans for a more preventive, person-centred, health and care system, but there is nothing to stop leaders being more ambitious about prevention right now.

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