Category Archives: Depressions

Brain tree: why we replenish only some of our cells | Daniel Glaser

We are being treated to a spectacular display of autumn colour this year, but it isn’t only trees that share this pattern for periodic shedding and regrowth. Our own skin cells, for example, are renewed every month or so, but we replenish less than 10% of our bone each year. Certain types of human cells do not seem to regenerate at all and this includes brain cells. With a few exceptions (such as the hippocampus), we are born with all the brain we’ll ever have. Over childhood and into adolescence, extensive pruning of the connections between cells takes place. This neural topiary shapes all the systems of the brain. But once into adulthood, although some new connections are formed, the main structural change is the steady death of our brain cells.

Many aspects of life cause our cells to die off, including trauma, drug use, environmental pollutants, strokes… and that’s before we start on age-related diseases such as Alzheimer’s. Yet the quality of our brain function doesn’t decline for most of adulthood. Maybe as our cells decrease we learn to adapt, picking up tricks to help us to make the best of what we’ve got.

Dr Daniel Glaser is director of Science Gallery at King’s College London

Cross-party MPs request urgent non-partisan debate on future of NHS

Ninety MPs including several senior Tories have urged Theresa May to launch a cross-party convention on the future of the NHS and social care in England.

Sarah Wollaston, chair of the Commons health committee, organised a letter in conjunction with the Liberal Democrat former care minister Norman Lamb and Labour’s former shadow care minister Liz Kendall, that has been sent to the prime minister and the chancellor, Philip Hammond.

The MPs say the health system has been failing patients and they call on Hammond to ensure any moves to lift the public sector pay cap for NHS workers is not funded by raiding existing health budgets.

The signatories, one-third of whom are Conservative MPs, have said only a non-partisan debate can deliver a “sustainable settlement”. They say the failure of normal party politics to secure the future of the system means a non-partisan approach is the only way to ensure action is taken, particularly given that the government does not command a majority.

“The need for action is greater now than ever,” say the MPs, who include about 30 former ministers. “We understand that fixing this is immensely challenging and involves difficult choices.

“We all recognise, though, that patients and those needing care are too often failed by a system under considerable strain. We believe that together we owe a duty of care to the people of this country to confront the serious challenges to the NHS and the social care system.”

The Tory signatories include the former education secretary Nicky Morgan, the former international development secretary Andrew Mitchell, George Freeman, a former policy adviser to May, and the party grandee Sir Nicholas Soames.

The Labour MPs who have signed include Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. Liberal Democrats signatories include the party leader, Sir Vince Cable, as well as Ed Davey and Tim Farron.

In a series of tweets Wollaston said:

Sarah Wollaston (@sarahwollaston)

. Govt also needs to focus on the long term, stop planning for health & social care in separate silos as this approach is setting us up for failure. Finance & workforce need urgent attention for the here & now but also for the long term & MPs from all Parties ready to engage

November 18, 2017

Sarah Wollaston (@sarahwollaston)

Current plans to kick social care into the long grass (again) & to separate planning for young and older adults creates even further fragmentation . Essential to think about whole system of NHS & Care

November 18, 2017

In the letter, MPs argue that only a cross-party NHS and social care convention where there can be a non-partisan debate can ensure a long-term settlement.

This was echoed by Wollaston in further comments in which she said: “The simple reality of a hung parliament means that all our constituents will be failed if long-term plans for NHS and [social] care funding do not command cross-party support.”

She added: “It’s better to take a joint approach to planning from the outset and actually deliver.”

Although MPs recognised that the challenge facing the government involved making difficult choices, they say “patients and those needing care are too often failed by a system under considerable strain”.

Lamb said: “Tribal politics has failed to provide a solution to the existential challenges facing the NHS and social care. We know that the current situation is unsustainable, and these pressures will only get worse as we contend with an ageing population and rising demand for care and treatment.

“This letter shows the strength of cross-party support for a new approach based on cooperation instead of political point-scoring. The fact that so many senior MPs and former cabinet ministers support this initiative is remarkable. Now the government must act on it.”

Kendall said: “Our population is ageing, more people need help and support and our care services desperately need more money to cope, yet any party that comes up with a significant proposal for funding social care risks their political opponents destroying them.

“We could carry on like this for yet another parliament, and yet another election, or we could face up to reality: we will only get lasting change if we secure a cross-party approach.”

According to NHS England chief executive, Simon Stevens, the fall per head in NHS funding means the health service will not be able to meet its routine waiting-time commitments.

Representatives from the Nuffield Trust, Health Foundation and King’s Fund said this year that austerity combined with increasing demand for services had created a “mounting toll on patient care”. They said there was growing evidence that access to some treatments was being rationed and that quality of care in some services was being diluted.

Solving the problem would mean a “steadily increasing share of national income would need to be spent on providing these services,” they said.

The UK spends 9.9% of GDP on the health budget – a considerably lower percentage than many other European nations.

Niall Dickson, chief executive of the NHS Confederation, which represents various organisations in the healthcare system, said promises to reform funding were being “kicked down the road”.

He said: “The government promised reform before the election, then said there would be a green paper before Christmas. Now it has been put off until summer next year – and even then we are not being promised firm commitments.”

A government spokesperson said: “We have announced a cross-government green paper on care and support for older people with input from a group of independent experts. We recognise that there is broad agreement across parliament that reform for social care is a priority and look forward to hearing a range of views.”

They said MPs would be consulted on social care before the green paper policy statement next year. The government had already provided an additional £2bn to social care over the next three years, the spokesperson said, adding that the government was committed to making the sector sustainable.

Cross-party MPs request urgent non-partisan debate on future of NHS

Ninety MPs including several senior Tories have urged Theresa May to launch a cross-party convention on the future of the NHS and social care in England.

Sarah Wollaston, chair of the Commons health committee, organised a letter in conjunction with the Liberal Democrat former care minister Norman Lamb and Labour’s former shadow care minister Liz Kendall, that has been sent to the prime minister and the chancellor, Philip Hammond.

The MPs say the health system has been failing patients and they call on Hammond to ensure any moves to lift the public sector pay cap for NHS workers is not funded by raiding existing health budgets.

The signatories, one-third of whom are Conservative MPs, have said only a non-partisan debate can deliver a “sustainable settlement”. They say the failure of normal party politics to secure the future of the system means a non-partisan approach is the only way to ensure action is taken, particularly given that the government does not command a majority.

“The need for action is greater now than ever,” say the MPs, who include about 30 former ministers. “We understand that fixing this is immensely challenging and involves difficult choices.

“We all recognise, though, that patients and those needing care are too often failed by a system under considerable strain. We believe that together we owe a duty of care to the people of this country to confront the serious challenges to the NHS and the social care system.”

The Tory signatories include the former education secretary Nicky Morgan, the former international development secretary Andrew Mitchell, George Freeman, a former policy adviser to May, and the party grandee Sir Nicholas Soames.

The Labour MPs who have signed include Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. Liberal Democrats signatories include the party leader, Sir Vince Cable, as well as Ed Davey and Tim Farron.

In a series of tweets Wollaston said:

Sarah Wollaston (@sarahwollaston)

. Govt also needs to focus on the long term, stop planning for health & social care in separate silos as this approach is setting us up for failure. Finance & workforce need urgent attention for the here & now but also for the long term & MPs from all Parties ready to engage

November 18, 2017

Sarah Wollaston (@sarahwollaston)

Current plans to kick social care into the long grass (again) & to separate planning for young and older adults creates even further fragmentation . Essential to think about whole system of NHS & Care

November 18, 2017

In the letter, MPs argue that only a cross-party NHS and social care convention where there can be a non-partisan debate can ensure a long-term settlement.

This was echoed by Wollaston in further comments in which she said: “The simple reality of a hung parliament means that all our constituents will be failed if long-term plans for NHS and [social] care funding do not command cross-party support.”

She added: “It’s better to take a joint approach to planning from the outset and actually deliver.”

Although MPs recognised that the challenge facing the government involved making difficult choices, they say “patients and those needing care are too often failed by a system under considerable strain”.

Lamb said: “Tribal politics has failed to provide a solution to the existential challenges facing the NHS and social care. We know that the current situation is unsustainable, and these pressures will only get worse as we contend with an ageing population and rising demand for care and treatment.

“This letter shows the strength of cross-party support for a new approach based on cooperation instead of political point-scoring. The fact that so many senior MPs and former cabinet ministers support this initiative is remarkable. Now the government must act on it.”

Kendall said: “Our population is ageing, more people need help and support and our care services desperately need more money to cope, yet any party that comes up with a significant proposal for funding social care risks their political opponents destroying them.

“We could carry on like this for yet another parliament, and yet another election, or we could face up to reality: we will only get lasting change if we secure a cross-party approach.”

According to NHS England chief executive, Simon Stevens, the fall per head in NHS funding means the health service will not be able to meet its routine waiting-time commitments.

Representatives from the Nuffield Trust, Health Foundation and King’s Fund said this year that austerity combined with increasing demand for services had created a “mounting toll on patient care”. They said there was growing evidence that access to some treatments was being rationed and that quality of care in some services was being diluted.

Solving the problem would mean a “steadily increasing share of national income would need to be spent on providing these services,” they said.

The UK spends 9.9% of GDP on the health budget – a considerably lower percentage than many other European nations.

Niall Dickson, chief executive of the NHS Confederation, which represents various organisations in the healthcare system, said promises to reform funding were being “kicked down the road”.

He said: “The government promised reform before the election, then said there would be a green paper before Christmas. Now it has been put off until summer next year – and even then we are not being promised firm commitments.”

A government spokesperson said: “We have announced a cross-government green paper on care and support for older people with input from a group of independent experts. We recognise that there is broad agreement across parliament that reform for social care is a priority and look forward to hearing a range of views.”

They said MPs would be consulted on social care before the green paper policy statement next year. The government had already provided an additional £2bn to social care over the next three years, the spokesperson said, adding that the government was committed to making the sector sustainable.

‘We are a force to be reckoned with’: voices of newly qualified nurses

‘I finish most shifts feeling guilty and remember things I didn’t have time to do’

Nursing isn’t what I expected it to be, there’s never enough time for patient contact which really saddens me. Nurses are now mainly office-based and have to delegate the patient contact to healthcare workers. I often class a good shift as one where I have managed to sit down and talk to someone who needed me. I finish most shifts feeling guilty and wake up in the middle of the night and remember things I didn’t have time to do. The stress of the job is unbelievable.

The pay conditions really anger me. Working in mental health can be a risky job where staff are assaulted and have to face quite a lot of abuse. I do not think it is fair that I only get paid around £10 an hour, which is a lot less than my friends who do low-level administration work in offices where they get paid to answer the phone. The government is relying on the good nature of nurses to continue doing their job because they care.
Kate Clayton, 15 months post-qualified, mental health nurse, Staffordshire

‘Nurses are a force to be reckoned with – I think that has become more prominent in recent years’

Before I began nursing I didn’t really see nurses as specialists or professors. It was only during my nursing studies and hospital placements that I began to realise the breadth of opportunities within nursing and the new found confidence nurses have. Nowadays we all work as a multidisciplinary team (MDT) and nurses work more closely with doctors and allied healthcare professionals. We, as nurses, are encouraged to speak up, ask questions and play a bigger part in the MDT and in our patients’ care plans. We also now have so many different opportunities for nurses like specialist roles, research and education. I think in the future we will see a lot more nurses going on to do the likes of PhDs and more specialist training. We are a force to be reckoned with and I think that has definitely become more prominent in recent years.
Bebhinn O’Dowd, 12 months post-qualified, critical care research nurse (specialising in major trauma), London

‘We are constantly working more hours than we should because it’s so short-staffed’

There is so much responsibility in modern nursing. You literally have people’s lives in your hands. It’s a big burden for a 22-year-old. Some older nurses have told me that in the past we would have been slowly fed into the system instead of being thrown in and immediately pushed to the limits. We are constantly working more hours than we ever should because it’s so short-staffed.


It seems more of an uphill battle to get what is deserved and to get the kind of respect nurses used to get

Liv Webster

Pay is of course something my friends and I rant about and some people who I studied nursing with have already changed their career path – we’re not even 18 months qualified. A lot are being pushed into private sectors and agency work so the NHS is losing valuable members of the team who can’t deal with the pay when they have families to support. Having said that I absolutely love my job and wouldn’t do anything else.
Ella Clarke-Billings, 14 months post qualified, surgical nurse, London

‘I didn’t realise the monumental amount of paperwork that nursing incorporated’

I went straight into the private sector due to more opportunity. I would have preferred to work for the NHS at the time but in my specialism I found it very hard to get into. I wanted to be a liaison nurse, which is a role to support people with a learning disability while they are in hospital, but people don’t seem to leave those jobs once they’re in them as they are so good to have. There is definitely more room for climbing the ladder in the NHS but that’s not what interests me. For me, getting the right healthcare for my service users and supporting them to have the best quality life they can is what’s most important. It’s why I wanted to become a nurse – to be the voice for those that couldn’t be heard and that’s what I can do in the company I work for.

I didn’t realise the monumental amount of paperwork that nursing incorporated. I definitely thought it would be more hands-on than it is. It seems more of an uphill battle to get what is deserved and to get the kind of respect nurses used to get, especially in my specialty which other health professionals seem to deem as useless. People don’t view learning disability nurses as proper nurses as we deal a lot with the social side and not just the medical side of care. I have even had family members joke that I’m not a proper nurse; when you aren’t given that level of respect it can really deflate you.
Liv Webster, 15 months post-qualified, learning disabilities nurse, Lichfield

‘Coming into nursing is different but it’s important to see it as a vocation rather than a job’

Nursing has certainly changed since I started in the early 1970s. The introduction of technology has had a big impact. I’ve seen the introduction of electronic health records, email and e-learning, and this kind of innovation has helped improve the practice of learning for the benefit of patients and carers. Many nurses had to adapt to the change and for some it was a difficult time as they did not have the computer skills required. For new nurses this will never be a problem as the way they study is academic and they have been brought up with technology.

But ultimately a good new nurse will have the same core skills and qualities, such as empathy and compassion, as when I trained. Coming into nursing now is different but it is even more important now that those entering see it as a vocation rather than a job. It is a hard career albeit rewarding.
Helen Smith, 41 years post qualified, mental health matron and ward manager, West Midlands

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.

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Brain game: bringing Paddington to life on screen | Daniel Glaser

The Paddington sequel, out this weekend, gives us a second helping of the antics of a fully computer generated lead character. In 1982 there was ET, but he was a puppet so physically existed on set. That was difficult enough, but CGI has other technical challenges. Fur is particularly problematic because of the complicated physics of the reflection of light from such irregular organic surfaces (even more difficult if the fur is covered in marmalade).

Giving the actors something to look at – Paddington will only come into the movie once filming has finished – poses even more problems because the actors must interact with something that isn’t there.

Since ancient times puppeteers have been able to produce human-like movements from simple bits of wood and string. Now it’s computer algorithms that translate biological essence into an artifical version.

Of course none of this would work were it not for our brains’ motor empathy which processes the film, giving the movements of a generated figure resonance – and thereby making Paddington such an attractive character.

Dr Daniel Glaser is director of Science Gallery at King’s College London

It’s true: Conservative governments really do kill people | Zoe Williams

There was a splenetic exchange on BBC Question Time last week, between an audience member and my colleague, Aditya Chakrabortty, who had pointed out that disabled people had died as a result of cuts to social security. You’re like “Donald Trump”, said a guy in the audience: the parallel was, Aditya had made a statement that was stirring, powerful, emotive and trenchant – so I guess, if we leave aside the fact that it was also true, it was pretty Trumpian.

Just as it’s verboten to call someone a liar in parliament, so there is a curious and ancient disapproval around pointing out that a state has been the direct cause of any deaths, whether of its own citizens or abroad. It is taken as hysterical overstatement (something that should only be levelled at an authoritarian regime, which takes its people out and shoots them) and pitiful naivety (a wilful misunderstanding of the business of government, to trace its policies crudely back to the lives of those who are affected by them).

Since “hysterical” and “naive” are two of the deadliest charges in political discourse, one always checks oneself before going full-pelt: we know that 90 people a month die after being declared fit for work, but can we really lay those deaths at the government’s feet? Plainly, they might have died anyway. All we can say about the Conservatives is that they instituted a disability assessment system that makes bad decisions, repeatedly, and causes untold trauma and desperation to people who are on the brink of death.

So let’s refine it: we know of the existence of 49 Department for Work and Pension reports – called peer reviews – that are triggered when someone dies following a cut to their benefits, 40 of which were suicides. They are heavily redacted, and what we can read of them does not amount to a straight causal link between a cut or sanction and a suicide.

The government – which will casually spend hundreds of thousands of pounds fighting a freedom of information request to release these peer reviews, and yet cannot afford to support a terminally ill cancer patient – has upended priorities when it comes to discussing the deaths of its citizens. It ploughs all its energy into denying a link between destitution and desperation, and apparently no energy at all into asking why these suicides occurred.

A much more striking example of that came in 2015, when there were 30,000 “excess deaths” in England and Wales, the greatest rise in mortality for 50 years, according to a study published this year. The researchers – from Oxford University, the London School of Hygiene and Tropical Medicine, and two borough councils – examined possible explanations and, having rejected environmental collapse, natural disaster and war, concluded that “the evidence points to a major failure of the health system, possibly exacerbated by failings in social care”, adding for clarity: “The impact of cuts resulting from the imposition of austerity on the NHS has been profound.”


People die having had their support system ripped from them and the response is a shrugging ‘whatever’

An unnamed Department of Health spokesman rejected the claim, citing “personal bias” of the authors (the truth has a liberal bias, as the saying goes), but strikingly, took no further interest in the matter. You would think that, even if someone vigorously denied responsibility for 30,000 excess deaths, they would at least ask where, then, responsibility lay.

Last year, meanwhile, the suicide rate within prisons in England and Wales reached an all-time high: 119 deaths, or one every three days. The background is a 40% drop in the number of prison officers, which had an obvious practical impact, pinpointed by Prof Pamela Taylor of the Royal College of Psychiatrists: there simply weren’t enough staff to accompany mentally ill patients to clinics and appointments.

But understaffing in prisons has much more profound atmospheric affects: it erodes officers’ capability to observe prisoners closely; to support those suffering a decline; to control bullies and legal highs; and to perform the subtle, invaluable, life-changing business of jail craft. Only a government with no insight at all into the prison estate would think you could shred its staff by nearly half and suffer no catastrophic effects.

Going right back to 2010, this is the enduring picture of Conservative government, which the Liberal Democrats still claim to have cushioned us from the worst of: not the parsimony, the defensiveness, the lack of curiosity when disasters occur, not the callousness or myopia, but the sheer indolence.

Decisions are made as if the consequences belonged to someone else. Judicial process is treated like long-grass. Ernest Ryder, senior president of tribunals, said last week that the DWP habitually provided evidence whose quality was so poor it would be “wholly inadmissible” in any other court. People die having had their support system ripped from them and the response is a shrugging “whatever”, plus maybe a blast of noise about bias and the last Labour government, like ducks flapping pointlessly on a pond. Every tactic is diversionary; the overarching strategy is, break it and see what happens.

Consensus now is that the Tories were governing, sometimes controversially but broadly effectively, when Brexit came along and capsized everything. This is mistaken: the referendum could only have been called, and the leave campaign only fought, by politicians with a fundamental lack of seriousness, a puerile indifference to the outcome of their decisions.

Long before it gambled with our future prosperity and place in the world, the Conservative party was shooting craps with the lives of its own people.

Zoe Williams is a Guardian columnist

Thousands with advanced cancer are surviving two years or more, data shows

Thousands of people in England with the most advanced stage of cancer are surviving for several years after diagnosis thanks to improved treatment and care, research shows.

Macmillan Cancer Support and Public Health England’s (PHE) National Cancer Registration and Analysis Service found that at least 17,000 people have survived for two years or more after being diagnosed with stage 4 cancer, when the disease has already spread to at least one other part of their body.

The figure, which has not previously been available, includes at least 1,600 women diagnosed with stage 4 breast cancer and 6,400 men diagnosed with stage 4 prostate cancer. It also includes at least 1,200 people diagnosed with stage 4 lung cancer and at least 2,300 people diagnosed with stage 4 bowel cancer.

Adrienne Betteley, Macmillan’s specialist adviser for end of life care, said: “Advances in treatment and care mean that a growing number of people have cancer that cannot be cured, but can be managed by treatments that alleviate the symptoms and may also prolong their life.

“This is really positive news, but living with advanced cancer can be a difficult situation to be in. As well as dealing with the physical symptoms of cancer and having multiple hospital appointments, scans and treatment options to contend with, there’s also the emotional and psychological impact of having an uncertain future.”

The research, revealed on Wednesday at the 2017 National Cancer Research Institute Conference in Liverpool, is based on data from England’s national cancer registry.

It captures people who were diagnosed with one of 10 common types of cancer between 2012 and 2013 and were still alive at the end of 2015.

The 17,000 is certain to be an underestimate, as there were a further 43,000 patients alive in 2015 who were diagnosed two to four years previously, but whose stage at diagnosis was not recorded in the registry. Many of those patients are also likely to have had stage 4 of the disease, also known as secondary or metastatic cancer.

Macmillan said the figures highlight the changing nature of the disease and expressed the hope that patients whose options were previously limited could see their cancer become more “treatable” and manageable, like other chronic illnesses.

Carol Fenton, 55, from London, was diagnosed with stage 4 breast cancer in 2015 and said her life since has been a “rollercoaster” of periods when her symptoms are settled and others when changes in scan results necessitate changes in treatment. She said: “It is hard to plan family activities a long way into the future, so we plan our life around my three-monthly scans. I’m concentrating on what I can do, rather than what I can’t, and I’m hoping that I will stay as well as possible for as long as possible, yet being realistic about preparing for when my condition progresses, not knowing if this will be in a few months, a year, or within five years or more.”

Several studies have suggested that cancer survival rates in the UK lag behind those of other European countries. For instance, survival rates for breast cancer are a decade behind countries including France and Sweden, according to one piece of research. Another found that the average adult five-year survival rates for patients diagnosed with eight common types of cancer between 2000 and 2007, were lower in the UK than the European average. Experts have flagged the need for earlier diagnosis and improved access to treatments.

Dr Jem Rashbass, cancer lead at PHE, said it was imperative people got diagnosed earlier, which was why the agency was running the Be Clear on Cancer campaigns to educate the public on the signs and symptoms of the disease.

Rashbass described the cancer registry data as “an invaluable resource in helping us to track improvements in cancer outcomes and gain more understanding of the implications for those living with and beyond a cancer diagnosis”.

The 10 types of cancer in the Macmillan and PHE study were: bladder; female breast; colorectal; kidney, renal pelvis and ureter; lung, trachea and bronchus; melanoma of skin; non-Hodgkin’s lymphoma; ovary; prostate and uterine cancer.

It’s not enough to train GPs in child protection. What happens next? | Zara Aziz

Following a colleague’s retirement I have now become the safeguarding lead for children at my GP practice. This means that I review cases, update our practice policies on safeguarding children and act as a liaison between staff, families, school nurses, paediatricians and social services. Like many other GPs, I come across cases of emotional or physical neglect through poverty, or parents having mental health or substance abuse problems.

Sometimes it is the police, A&E or health visitors who alert me to concerns they have about a child’s welfare. But worryingly, for every child on the child protection register there are another eight who are not known to agencies, according to the NSPCC. And this can only get worse as cuts to local authority children’s services continue.


The reality is that the child protection system is simply unable to keep up with demand

Since 2013, the Care Quality Commission asks that all GPs do at least two hours’ safeguarding training a year. Mine has focused on real cases of neglect and abuse. We discuss these cases, with failings highlighted often at multiple points where a child may have come into contact with health professionals. It has helped us to make informed and early referrals to child protection.

The decision to make a safeguarding referral is not one taken lightly. But once done, often help is either very hard to access or just not available. It’s usually not the social worker’s fault: the reality is that the child protection system is simply unable to keep up with demand.

For example, when I refer Daisy (not her real name), who is three years old, to the child protection team for neglect, her mother is struggling with alcohol use and Daisy is malnourished and physically and emotionally left to fend for herself. Her nursery attendance is poor. After some delay, the social worker decides that Daisy should not have a child protection plan but is a child in need instead (an allocation that comes with little resources or practical support for Daisy or her mother). The system’s focus is on severe cases (such as those of physical or sexual abuse) rather than prevention through early help for less severe cases.

Children’s social services have lost £2bn in savage funding cuts, despite the growth in safeguarding referrals, up 15% between 2013 and 2016 for adults and children. Vacancy rates for social workers are high and long-term sickness common, meaning caseloads often have to be reallocated. Children’s social services cuts have also slashed the early help and intervention that young people and families used to receive, such as through Sure Start or similar schemes).

Social workers do a very difficult job in a system under huge strain. Yet, from a doctor’s perspective, it often feels as if the threshold for accepting safeguarding referrals is governed more by the level of demand or staffing on the day than the severity of the case. This is particularly true for issues of neglect or where there are parental mental health or substance misuse problems, when I have been asked to access help for the parent, rather than focus on the child as well.

My experience is echoed across the country. Many GPs says they find it hard to access timely support from social services and lengthy delays, unclear pathways or ineffective responses to safeguarding concerns are common complaints. Where is the effective response for them when thresholds for taking action remain ambiguous or sky high, or funding cuts mean that early help is lacking?

As GPs become more proficient in spotting the signs of neglect and abuse, we are likely to make more safeguarding referrals. But without more funding for children’s services, we will be only adding to the pressure on social workers.

It seems ill-conceived that the government has pushed for widespread safeguarding training, but not planned at all for its aftermath. ​

Zara Aziz is a GP partner in north-east Bristol

World’s most unusual commutes: share your pictures and stories

A strong coffee and a good book is, for many people, all that’s required to get through the journey to work. But for those who prefer to beat the rush hour by swimming, kitesurfing or paragliding to the office, the daily commute can be a little more demanding and a lot more fun.

Do you avoid traffic jams and packed trains by commuting on horseback or climbing into a canoe? We want to hear from those intrepid readers around the world who opt for more unusual means to get to work – such as Benjamin David, who swims 1.2 miles (2km) down the Isar in Munich everyday.

If your commute is out of the ordinary, we’d like to see what it looks like and hear about your experiences. Show us your pictures and tell us what you enjoy most about your journey and how and why you’ve turned your commute into a daily adventure. We will feature some of the best stories and photos in a gallery and accompanying article.

Share your commuting experiences with us now by clicking on one of the blue “contribute” buttons – or, if you’re out and about, you can also use the Guardian app and search for “GuardianWitness assignments”.

  • GuardianWitness is the home of user-generated content on the Guardian. Contribute your video, pictures and stories, and browse news, reviews and creations submitted by others. Posts will be reviewed prior to publication on GuardianWitness, and the best pieces will feature on the Guardian site.

World’s most unusual commutes: share your pictures and stories

A strong coffee and a good book is, for many people, all that’s required to get through the journey to work. But for those who prefer to beat the rush hour by swimming, kitesurfing or paragliding to the office, the daily commute can be a little more demanding and a lot more fun.

Do you avoid traffic jams and packed trains by commuting on horseback or climbing into a canoe? We want to hear from those intrepid readers around the world who opt for more unusual means to get to work – such as Benjamin David, who swims 1.2 miles (2km) down the Isar in Munich everyday.

If your commute is out of the ordinary, we’d like to see what it looks like and hear about your experiences. Show us your pictures and tell us what you enjoy most about your journey and how and why you’ve turned your commute into a daily adventure. We will feature some of the best stories and photos in a gallery and accompanying article.

Share your commuting experiences with us now by clicking on one of the blue “contribute” buttons – or, if you’re out and about, you can also use the Guardian app and search for “GuardianWitness assignments”.

  • GuardianWitness is the home of user-generated content on the Guardian. Contribute your video, pictures and stories, and browse news, reviews and creations submitted by others. Posts will be reviewed prior to publication on GuardianWitness, and the best pieces will feature on the Guardian site.