Complications from medical cosmetic tourism result in costs to the NHS

My Post (15)While many patients venture outside of the UK for cosmetic surgery, due to the significant cost of private care in the UK, there is also a lucrative business for non-invasive aesthetic treatments abroad. In the UK, botulinum toxin injections or dermal fillers cost about £150–£350 per session, depending on the amount of product used (NHS Choices, 2016a). Chemical peels cost about £60–£100 for mild peels, with deeper treatments often costing over £500 (NHS Choices, 2016a). The cost of cosmetic micropigmentation varies from £75 for a beauty spot to £500 for lip liner (NHS Choices, 2016a). Microdermabrasion costs £40–80 for a single session (NHS Choices, 2016a).

By contrast, costs for treatments abroad can be substantially cheaper. For example, prices for botulinum toxin can be as low as £40 in Thailand, £50 in the United Arab Emirates and £60 in the Czech Republic (MEDIGO, 2017a). Chemical peels start from £22 in Thailand, £44 in Turkey and £45 in Malaysia (MEDIGO, 2017b).

Complications of non-surgical cosmetic treatment

Complications arising from non-invasive cosmetic treatments are less common and often less severe than those from surgical procedures. However, there is still a notable element of risk involved.

The most common complications from botulinum toxin and soft-tissue filler injections are bruising, erythema and pain (Levy and Emer, 2012). Erythema is also not uncommon following chemical peels, as well as irritation and burning (Levy and Emer, 2012). These side effects are generally temporary and easy to treat. More serious complications include muscle paralysis from botulinum toxin, granuloma formation from soft-tissue filler placement, and scarring from chemical peels (Levy and Emer, 2017).

Issues regarding regulation

In 2013, Sir Bruce Keogh was asked to undertake a review into the regulation of cosmetic interventions in the UK. It revealed that non-surgical interventions were almost entirely unregulated, with no restrictions on who may perform procedures (Department of Health (DH), 2013). This poses a significant risk to patients, as without accredited training, practitioners are unlikely to recognise complications of the procedures, or be able to treat them. The review committee therefore recommended approved training schemes were introduced, as well as accredited qualifications, and associated registers for both surgical and non-surgical cosmetic procedures.

The DH (2014) provided a response to this review, largely accepting many of the recommendations, but did not believe a new regulated profession for those performing cosmetic procedures should be introduced, as many practitioners were already members of professional registers and so subject to regulation. In 2015, Health Education England (HEE) unveiled new qualifications to improve the safety of non-surgical cosmetic procedures (HEE, 2015), but again did not go as far as to establish legal requirements for the administration of non-surgical cosmetic interventions.

Issues concerning regulation for non-surgical cosmetic interventions also exist in other countries. Due to differences in standards and qualifications, it can be difficult to establish the suitability of a practitioner to carry out an intervention. In Europe, dermal fillers are regarded as medical devices requiring only Conformité Européenne certification (Hachach- Haram et al, 2013). It is only in the US that dermal fillers are seen as medicines and are therefore required to be approved by the US Food and Drug Administration (Hachach- Haram et al, 2013).

Whose responsibility is follow-up care?

Follow-up care is an important part of treatment, particularly in the case of cosmetic surgery. The NHS advises that when making enquiries about treatment abroad, it is important to know how complications would be handled, what would happen if revision surgery was needed after the original procedure, and how much it might cost (NHS Choices, 2016b). Unfortunately, all too often the expectation in the UK is that if something goes wrong, the NHS will sort it.

It is believed the cost to the NHS of fixing botched botulinum toxin injections could be as much as £1 million a year (Savage, 2016). However, because of a lack of data, it is difficult to accurately gauge the cost to the NHS of fixing cosmetic complications, or to establish the numbers of complications attributable to UK private care, treatment abroad or self-administration.

It has been questioned whether cases should be considered individually, whether guidelines and standards of treatment need to be outlined, or whether treatment by the NHS should be strictly limited to acute cases only (Hachach-Haram et al, 2013).

Additionally, there is limited knowledge of public attitudes towards the regulation and safety of treatment. People considering this type of treatment need to be aware of the risks and thoroughly research the practitioners who will be carrying out their treatment. Many websites offer holiday packages of treatment, travel and accommodation, but can be misleading in what it is they are providing.

It is clear that tighter rules regarding regulation are needed globally, along with clear outlines of practitioners’ aftercare responsibilities and improved education around the possible risks for prospective patients. Without this regulation, it is evident the NHS will continue to pick up the bill when things go wrong.

References

Department of Health. Review of the regulation of cosmetic interventions: final report. 2013. https://tinyurl.com/b8qq6ek (accessed 11 January 2018)

Department of Health. Government response to the review of the regulation of cosmetic interventions. 2014. https://tinyurl.com/nnjvlym (accessed 11 January 2018)

Hachach-Haram N, Gregori M, Kirkpatrick N, Young R, Collier J. Complications of facial fillers: resource implications for NHS hospitals. BMJ Case Rep. 2013; pii: bcr-2012-007141. https://doi.org/10.1136/bcr-2012-007141

Health Education England. Qualification requirements for delivery of cosmetic procedures: non-surgical cosmetic interventions and hair restoration surgery. 2015. https://tinyurl.com/z43cs8s (accessed 11 January 2018)

Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121– 132. https://doi.org/10.4103/0974-2077.99451

MEDIGO. Botox injections and wrinkle treatment at clinics and hospitals worldwide. 2017a. https://tinyurl.com/yd3xzu34 (accessed 11 January 2018)

MEDIGO. Chemical peel at clinics and hospitals worldwide. 2017b. https://tinyurl.com/ycwe3y72 (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures. 2016a. https://tinyurl.com/yae8sdyt (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures: Cosmetic surgery abroad. London: NHS Choices; 2016b. https://tinyurl.com/ydckt79p (accessed 18 January 2018)

Savage M. Up to £1m a year spent fixing bad Botox. 2016. https://tinyurl.com/y7dfn9jh (accessed 11 January 2018)

Taken from Journal of Aesthetic Nursing, published February 2018.

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More nurses leaving the profession than joining, figures show

My Post (10)More registered nurses are leaving the profession than joining, analysis by the Nursing and Midwifery Council (NMC) has revealed. First published in July, the data showed that the overall number of leavers has increased from 23 087 in 2012/13 to 34 941 last year (NMC, 2017a). By contrast, the number of initial joiners was 29 025 for 2016/17.

Jackie Smith, NMC Chief Executive and Registrar, said: ‘At a time of increased pressure on the healthcare workforce to deliver quality patient care, we hope our data will provide evidence to support government and employers to look in detail at how they can reverse this trend.’

Recent figures reveal that the number of registered nurses has continued to decline, with 27% more people leaving the register than joining between October 2016 and September 2017 (NMC, 2017b).

‘These alarming new figures represent a double whammy for the NHS and patients,’ said Royal College of Nursing (RCN) Chief Executive Janet Davies.

‘Not only has the number of UK nurses quitting the profession gone up, but significant numbers of EU-trained nurses on whom the health service depends are leaving and there’s been a huge drop in nursing staff coming to work here from EU countries.’

The number of nurses and midwives from Europe leaving the register has increased by 67%, while the number joining the register from the EU has dropped by 89%.

Although the NMC does not have separate figures for the number of practice nurses leaving the profession, records show that in March 2017 there were 15 528 full-time equivalent practice nurses. This represents a decrease of 225 since March 2016 (NHS Digital, 2017). The number of European nurses joining and leaving general practice is unclear.

Why are nurses leaving?

One of the key reasons nurses are leaving the register is because an increasing number are reaching retirement. Nurses of the ‘baby boomer’ generation are now able to claim their NHS pension, and many are choosing to do so. Under the NHS pension scheme, nurses who were working on or before 6 March 1995 have the right to retire at 55 without any reductions in their pension.

‘Nursing and midwifery are widely acknowledged to be ageing professions, with significant numbers on the register coming up to retirement age,’ said Ms Smith.

It is this factor, combined with increasing workloads, that is encouraging nurses to leave the profession early said Crystal Oldman, Chief Executive of the Queen’s Nursing Institute. ‘I think what’s happening is with the increasing demands on individual nurses in their areas of practice, those at that age—between 55 and 65—are saying, “you know what, this is not what I joined to do,”’ she said.

‘“I am not able to give the care that I used to be able to give, so I’m going to retire now. I’m not going to revalidate, I’ll come off the register, I’ll take my pension.”’

Jenny Aston, Royal College of General Practitioners Nurse Champion, agrees that retirement is the main reason for increasing numbers of practice nurses leaving. ‘The QNI survey that was done a few years ago suggests that there are about 30% due to retire in the next 2–3 years,’ she said. ‘That’s going to be a massive number, unless for some reason they wish to stay on or are encouraged to stay on.’

Valerie Ely, 58, is a registered nurse and senior lecturer at Huddersfield University who is in the process of taking voluntary severance. She went part time at 55, because to remain a manager she was required by the university to do a PhD.

‘I am sad about it and to some extent a bit bitter, but I am 58 so have to accept it,’ she said. ‘A PhD would be 6 years part time and it’s really performance managed.’

‘The irony of my redundancy date is that it’s the same day I would have had to renew registration and revalidate. I have not been clinical for some years and it’s unlikely I’m going to get a job at another university, so I don’t feel that I have many options to stay on the register,’ she added.

But not all those leaving are of retirement age. Of those who didn’t cite this as their reason for leaving, the average age has reduced from 55 in 2013 to 51 in 2017. Additionally, the numbers of leavers aged 21–30 years has increased from 1 510 in 2012/13 to 2 901 in 2016/17.

A survey of 4 500 nurses and midwives carried out by the NMC revealed that working conditions, a change in personal circumstances, and a disillusionment with the quality of care provided to patients were also cited as reasons for leaving.

Sarah is a lead practice nurse at a GP surgery in South Yorkshire. She has been a practice nurse for 9.5 years but is leaving to take up a respiratory nurse role at a hospital trust. She is hoping the new job will bring back her passion for nursing.

‘As nurses experience tougher work conditions, the importance of ensuring they are valued cannot be understated’.

‘Although I enjoy the variety within the role, I am increasingly feeling overwhelmed with the extent of the knowledge and skills I need to be competent to do my job,’ she said. ‘There are only two nurses at my surgery, so we both need to be able to do everything within the practice nurse remit.’

As nurses experience tougher work conditions, the importance of ensuring they are valued cannot be understated. Kathryn Yates, Professional Lead for Primary, Community and Integrated Care at the RCN, thinks that the feedback from patients, families and carers about the outstanding care they receive from general practice nurses is incredibly important.

‘We need to continue to raise the profile of general practice nurses and how valued they are,’ she said. ‘I think we need more evidence to support that.’

Additionally, Dr Oldman says that, due to increased workloads, many nurses are finding themselves no longer doing the job they were trained to do. This understandably causes frustration and a decrease in job satisfaction. ‘They may not be leaving if the conditions were suitable for them to give the best possible care they want to give,’ she said. ‘We have a lot of anecdotal evidence from nurses who say, “I would stay, but I can’t do the job I was trained to do.”’

This lack of being valued is at the heart of why Sarah decided to leave practice nursing. ‘There is a lack of understanding and awareness of what practice nursing involves, which has an impact on others’ expectations,’ she said. ‘It is viewed by the public and other nurses/health professionals as an easy job, with nice hours and none of the pressures that are obvious in hospitals, emergency departments etc.

Our contribution is usually overlooked or any achievements attributed to GPs.’

Combatting the problem

Central to the issue of recruitment and retention is a workforce plan that ensures there are sufficient numbers of nurses now and in the future. A clear workforce plan also allows for accountability when those numbers aren’t met.

Crystal Oldman said: ‘I think the issue is about having a robust workforce plan and also having accountability for that somewhere centrally. Each individual provider must have its own workforce plan, but we are a national health service. What I would like to see is a national workforce plan for registered nurses.’

Kathryn Yates supports this but adds: ‘If we signpost to one particular organisation, it may devolve responsibility. I think there is also a sense of being mindful of how organisations work together to try and come up with real-time solutions.’

For Jenny Aston focusing on training the next generation and making nursing an attractive career is key. ‘Nursing isn’t going to change over the next 10 years: there are still going to be injections, there is still going to be lots of wound care, there is still going to be a need to monitor patients’ health,’ she said. ‘The work is not going away. There may be bigger practices, but I don’t see the nursing activity changing and, therefore, there is going to be an ongoing need to train up the next generation because 30% are going to be retired in 3 years’ time.’

Additionally, there need to be incentives for nurses not to retire early. ‘What lots of people don’t realise is that there are ways to stay on, claim your pension and make your pension arrangements different, so you don’t lose out on the final salary [pension benefits],’ said Ms Aston. ‘But I don’t think many nurses have good financial advice on how they get the best out of staying in work.’

Most importantly, nurses have to be listened to, so their concerns are understood and they feel valued. According to Kathryn Yates, it may be unclear what their needs are: ‘Going forward we may have a workforce that wants to work differently, and we must continue to make nursing an attractive and first destination career.’ she said.

Maria Caulfield, former nurse and Conservative MP for Lewes, said: ‘While I welcome the fact that more nurses are entering the profession than ever before, I am concerned that we are losing large numbers of our most experienced nurses, who are retiring or leaving the profession early. As a result, overall nursing numbers remain static at a time when the demand and need for nurses are increasing. There are a variety of reasons why nurses are leaving and certainly the pay freeze and cap have not helped morale, but from talking to colleagues it is the lack of overall recognition and feeling of worth that has led to many walking away. This is why I have lobbied ministers to ensure nurses are recognised. Lifting the pay cap is one way to show this.’

Health Education England oversees education and training of NHS staff. It has identified the need for additional supplies of nurses and improved rates of employment for graduates. Closing current shortages will also help with moderating increasing workloads.

NHS Improvement has launched a programme to improve retention of NHS staff by 2020. It will look at reasons why staff are leaving to help understand how to improve retention rates.

References

NHS Digital. General and Personal Medical Services, England March 2017. https://digital.nhs.uk/catalogue/PUB30044 (accessed 13 December 2017)

Nursing and Midwifery Council. The NMC Register: 2012/13–2016/17. 2017a. https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/nmc-register-2013-2017.pdf (accessed 13 December 2017)

Nursing and Midwifery Council. The NMC Register: 30 September 2017. 2017b. https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/the-nmc-register-30-september-2017.pdf (accessed 13 December 2017)

British Thoracic Society/Scottish Intercollegiate Guidelines Network. SIGN 153. British guideline on the management of asthma 2016. 2016. https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (accessed 19 December 2017)

National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. 2017. https://www.nice.org.uk/guidance/ng80 (accessed 19 December 2017)

Taken from Practice Nursing, published January 2018.

Whole system change needed in gender identity services

My Post (5)Gender identity services in the NHS are failing to meet the needs of patients. Huge delays in treatment are forcing many to go private or abroad, while a lack of funding and suitably trained staff means patients are not receiving adequate care.

Gender dysphoria is a condition whereby a person experiences discomfort or distress because there is a mismatch between their biological sex and their gender identity (NHS Choices, 2016). Figures estimate there are 650 000 people in the UK living with gender dysphoria, which is equal to 1% of the population (Women and Equalities Committee, 2016). This is expected to rise as society’s increasing tolerance and acceptance of transgenderism has encouraged more people to come forward and seek medical help.

In the UK, transgender people’s health needs regarding gender dysphoria are being met at specialised NHS gender identity clinics or through private care. At present, all GPs in England, Northern Ireland and Scotland may refer their patients directly to a gender identity clinic, and do not need to refer them to a mental health service for assessment beforehand. In Wales, however, GPs have to refer first to a local psychiatrist, who assesses the patient and can recommend they are referred for assessment and treatment at a gender identity clinic (General Medical Council (GMC), 2017).

Unacceptable waiting times

Waiting times for people with gender dysphoria before their first appointment at an NHS gender identity clinic are unacceptable, as are the times for subsequent gender reassignment surgery, should it be wanted. This, in turn, has a massive impact on the health and wellbeing of trans patients. According to the GMC, the risk of self-harm and suicide for trans people is much greater than in the general population, and any delays in accessing medical care can substantially increase these risks (GMC, 2017).

Under the NHS Constitution, patients are legally entitled to have their first appointment at a specialist service within 18 weeks of referral (Department of Health, 2015). However, due to increased demand, some transgender patients have found themselves waiting up to 4 years for an appointment (Lyons, 2016). Remarkably, it was only in January 2015 that the NHS accepted that the 18-week principle applies to gender identity services too (Women and Equalities Committee, 2016).

It is because of these long waiting times that many trans people are turning to private care—but this does not come cheap. Initial appointments can cost between £220 and £280, and tend to cover assessment, diagnosis and recommendations. It is generally after two appointments that hormone therapy is started.

The cost of gender reassignment surgery varies considerably and prices range from £10 000 to £20 000. In desperation, many are turning to far-flung destinations, such as Thailand, to have this surgery.

Things need to change

In an attempt to meet the increased demand on gender identity services, NHS England invested an additional £6.5 million in this area this year. It is hoped this will go some way to reducing waiting times. However, despite increased funding, there is no detracting from the stark truth that the NHS is letting transgender people down. Notably, according to a Government report on transgender equality, the NHS is ‘failing in its legal duty under the Equality Act’ (Women and Equalities Committee, 2016).

A lack of knowledge and understanding among many clinicians and staff within the NHS has meant transgender people all too often encounter significant problems, whether through prejudice or the provision of inappropriate care. Additionally, other commonly cited concerns include too much variation in clinical protocols, confusion about what is available in the NHS, and inequitable access arrangements (Women and Equalities Committee, 2016).

Following this report, NHS England asked its Clinical Reference Group for Gender Identity to make recommendations on new service specifications for these specialist clinics. This led to a 12-week public consultation on proposals for new service specifications that, if adopted, will describe how specialised gender identity services for adults will be commissioned and delivered in the future within England. The final decisions will be made at the end of autumn 2017.

Relationship between public and private services

Among the changes set out in the consultation include a proposal that only designated specialist gender identity clinics will be able to refer individuals for reassignment surgery in the NHS. This would mean other NHS professionals or private clinics would not be able to make the referrals. The decision was made because it is felt the multidisciplinary teams of gender identity clinics are best placed to consider an individual’s suitability for surgery in the context of the relevant medical, psychological, emotional and social issues (NHS England, 2017). They are also able to accurately gauge the likely range of risks in each case.

Unfortunately this means patients would be unable to begin down the private pathway of care for an initial assessment and diagnosis, before moving to the NHS for gender reassignment surgery. Though this would go some way to diverting pressures on NHS services, it could be argued that boundaries of care between private and public could be blurred, making it difficulty to ensure safety and quality of care. Equally, referrals to an NHS gender clinic would have to come through an NHS pathway.

A gender identity specialism is needed

The lack of suitably trained staff to take on specialist roles being created in nursing, medicine, psychology and other professions is one of the key reasons for unprecedented demand on gender identity services. There are under a dozen people in the UK working both privately and in the NHS who can carry out vaginoplasty or phalloplasty operations (Parkins, 2016).

With the above in mind, there have been discussions with Health Education England, the GMC and the Royal College of Physicians about the development of a gender identity specialism, supported by appropriate curricula and recognition. It is evident that this is sorely needed; however, even at a grassroots level, training for GPs is insufficient, consisting of two online educational modules on gender variance on the Royal College of General Practitioners’ website. Without a proper understanding of this patient population, health services cannot begin to address their needs.

Conclusion

While momentum for change is gathering and the Government is beginning to listen, anything short of a whole system change in gender identity services would be insufficient. Waiting times are the most pressing concern that need to be addressed, with demand and capacity out of balance. Quality indicators are needed to assess quality and benchmark providers; a better interface with primary care services is essential; and increased understanding and knowledge across all health services is paramount. Transgender people have just as much right to care as anyone else, and health services and professionals cannot let them down.

References

Department of Health. NHS Constitution for England. 2015. http://tinyurl.com/d7sa3wq (accessed 23 October 2017)

General Medical Council. Good medical practice. Trans healthcare. Treatment pathways. 2017. http://tinyurl.com/grugw8z (accessed 19 October 2017)

Lyons K. Gender identity clinic services under strain as referral rates soar. 2016. http://tinyurl.com/hcb9uzz (accessed 19 October 2017)

NHS Choices. Gender dysphoria. 2016. http://tinyurl.com/ybt7rbj7 (accessed 19 October 2017)

NHS England. Guide to consultation: specialised gender identity services for adults. 2017. http://tinyurl.com/ydg3pfmh (accessed 19 October 2017)

Parkins K. Meet the gender reassignment surgeons: ‘Demand is going through the roof’. 2016. http://tinyurl.com/hdblcpg (accessed 19 October 2017)

Women and Equalities Committee. Transgender equality: first report of session 2015–16. 2016. http://tinyurl.com/y8sftc2h (accessed 19 October 2017)

Taken from Journal of Aesthetic Nursing, published November 2017.

Review of Mental Health Act must address excessive detention rates

My Post (4)Theresa May’s speech at the Conservative Party Conference on Wednesday 4 October was one mired by illness, a prankster and a backdrop that fell apart, presenting journalists with countless opportunities for cheap metaphors. But while the gaffs of her mea culpa overshadowed the announcement of new policies, for those that could see past the cringe-induced spectacle there were a number of interesting points.

One of these announcements was how the Government would be carrying out an independent review of the Mental Health Act. Building on her Brexit speech in January, where she vowed to correct the ‘burning injustices’ in modern society, May explained how a particular priority for her was ‘tackling the injustice and stigma associated with mental health’ (May, 2017).

She emphasised her desire for parity between mental and physical health through reiterating the Government’s pledge of increased investment in mental health. Recent announcements of an additional £1.3 billion to transform mental health services by 2021 (Health Education England, (HEE), 2017) were met with mixed reactions from key health bodies. It was said the funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services (Department of Health, 2017). However, organisations such as the Royal College of Nursing said the Government’s proposals ‘appear not to add up’ (Royal College of Nursing, 2017). Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

The Mental Health Act

The Mental Health Act was passed in 1983 and is the main piece of legislation that sets out when and how a person can be detained and treated in relation to their mental illness. People detained under the Mental Health Act need urgent treatment for a mental health disorder and are deemed to be at risk of harm to themselves or others. In May’s speech she argued that the three decades old legislation is leading to ‘shortfalls in services and is open to misuse’ (May 2017). While the Mental Health Act was amended in 2007, it is felt by many that a more substantial revision is needed. This amendment was originally a proposed bill, but many felt it was ‘too draconian’ (BBC news, 2007).

The Five Year Forward View for Mental Health called for the Mental Health Act to be revised ‘to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will’ (Mental Health Taskforce, 2016).

Reducing detention rates

Current detention rates under the Mental Health Act are too high. The latest published figures show the number of detentions under the Act are rising annually, increasing by 9% to 63 622 in 2015–2016, compared to 58 399 detentions in 2014–2015 (NHS Digital, 2016). Over the last 10 years they have increased by almost 50%. Of those detentions, a disproportionate number are of people from black and minority ethnic populations — four times as many black people as white people are detained. It is unclear why there are disproportionate detention rates between different communities, but this must be identified to ensure equal access to earlier intervention and crisis care services.

While reviewing the Act will use changes in legislation to help reduce the rates of detention, the difficulty will come in figuring out how the delivery of care must be changed so that detention can be avoided in the first place (Wessely, 2017). Additional focus is needed on the provision of earlier support. By identifying vulnerable people and addressing their mental health needs early, they can receive the support and care they need before detention becomes an unavoidable necessity.

For those that are detained, there needs to be a review of the areas constituting a ‘place of safety’. Police custody is not an appropriate area of safety. Around half the deaths that take place in or following police custody involve detainees with some form of mental health problem (Independent Police Complaints Commission (IPCC), 2017). Although police custody is only used as a last resort, it can exacerbate a person’s mental state, and has the effect of criminalising people who are in need of medical attention (IPCC, 2017).

Undertaking the review

The review will be carried out by Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. He is the former President of the Royal College of Psychiatrists and current President of the Royal Society of Medicine. Wessely will produce an interim report in early 2018 and develop a final report containing detailed recommendations, by autumn 2018.

References

BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm

Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-theprevention-of-mental-health-problems/

Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf

Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody

May T. Theresa May’s Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservativeconference-speech-full-text/

Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016

NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016

Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq

Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain – Here’s Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simonwessely/mental-health-act_b_18192476.html

Taken from British Journal of Healthcare Management, published November 2017.

Government’s additional £1.3 billion for mental health services is misleading

Adobe Spark (4)The Government has committed £1.3 billion to transform mental health services by 2021 (Health Education England (HEE), 2017). Stepping Forward to 2020/21: Mental Health Workforce Plan for England was launched by Health Secretary Jeremy Hunt, who called it ‘one of the biggest expansions of mental health services in Europe’ (Department of Health, 2017). The funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services.

Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

Examining the plan

The scale of these proposals is commendable and reflects the additional staff required to deliver the transformation set out in The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016). Mental health provision has consistently been underfunded, therefore an update to place it more in line with physical health provision is long overdue.

For this reason, the announcement has been welcomed by many mental health campaigners and professionals. The Royal College of Psychiatrists (RCP) led the way in commending the Government’s plans, with Professor Wendy Burn, President of the RCP, saying the 570 extra consultants promised in the strategy will be ‘crucial to delivering the high-quality, robust mental health services of the future’ (RCP, 2017). NHS Employers said service providers will welcome national support, particularly for ‘improved access to funding for continuing professional development for the mental health workforce, and facilitating increased use of international staff where required’ (NHS Employers, 2017).

However, despite the will to welcome these proposals it would be wise to take them with a pinch of salt. While the Royal College of Nursing (RCN) encouraged the investment, it said the Government’s proposals ‘appear not to add up’ (RCN, 2017). RCN chief executive, Janet Davies, stressed that in order for the nurses to be ready in time, they would have to start training straight away. Additionally, she cites how the scrapping of nursing bursaries has led to a ‘sharp fall in university applications’.

Attrition rates on the rise

Attrition rates for all mental health staff are rising. From 2012/13 to 2015/16, the number of people leaving mental health trusts has risen from 10.5% to 13.6% (HEE, 2017). The NHS currently funds over 214 000 posts to provide specialist mental health services in England. However, over 20 000 of these vacancies are predominantly filled by bank and agency staff (HEE, 2017). It is clear the sheer scale of growth cannot be met via the traditional training routes within this timescale, as in some cases this would mean doubling or trebling the workforce. While investment is needed in the development and reskilling of existing staff, or looking to the global market for recruitment, this is an unrealistic aim.

The Royal College of Occupational Therapists (RCOT) is one of the groups who have raised concerns over vacancy rates. Julia Scott, CEO of the RCOT, said health and care services across the country are experiencing real difficulties in filling existing vacancies, with vacancy rates for occupational therapists of up to 50% (RCOT, 2017). She stressed that rapid action is needed to address this crisis if commitment is to be delivered.

The British Medical Association (BMA) echoed worries over recruitment, stressing insufficient psychiatry trainees across England and a high percentage of trainees not completing training in the specialty. BMA consultants committee deputy chair and consultant child and adolescent psychiatrist, Dr Gary Wannan, said: ‘In 2014, one in five doctors undertaking core psychiatry training did not progress into the final part of their training’ (BMA, 2017).

Government pledge still insufficient

Currently, 15.8% of people with common mental conditions access psychological therapies each year. However, even with the Government’s proposals this will only increase to 25% by 2020/21 (HEE, 2017). This is still an unacceptable figure
and one that is emphasised by the UK Council for Psychotherapy (UKCP), who said the announcement falls far short of what is needed to offset the growing demand for NHS mental health services.

According to UKCP Chair Martin Pollecoff: ‘To meet even existing demand, the Government should take advantage of the vast existing workforce of therapists. UKCP alone has more than 8000 highly qualified trained psychotherapists from different backgrounds, and many of them have medical experience’ (UKCP, 2017).

Origin of investment misleading

This is not the first time the introduction of £1 billion for mental health services has been proposed. In 2016, then Prime Minister David Cameron announced almost £1 billion of investment as part of a ‘revolution’ of mental health treatment (Prime Minister’s Office et al, 2016). This commitment from the Government sounds impressive, but has to be considered in the context of cash terms rise in the NHS budget generally. The Government has pledged to increase NHS spending in England to £120 billion by 2020/21
(HM Treasury, 2015). For mental health spending to grow at the same rate as the rest of the NHS, around 11.9% of the extra funding given to NHS England needs to be spent on mental health (Full Fact, 2016). This works out at roughly £2.2 billion. This figure far exceeds the £1.4 billion pledged in the most recent announcement and clearly represents a slower rise in spending than other parts of the NHS.

Simply not good enough

At first glance, the Government’s proposals appear to be the desperately needed boost to mental health services, which should be welcomed. However, the explanations of how additional posts will be funded or the recruitment issues overcome does not add up and are simply not good enough.

The Government has sugar-coated the amount of investment pledged and the figure still falls far below what is needed for mental health. It therefore comes as no surprise that Labour’s Shadow Minister for Mental Health, Barbara Keeley MP, said the workforce plan: ‘offers little hope to those working in the sector faced with mounting workloads, low pay and poor morale’ (The Labour Party, 2017).

References

British Medical Association (2017) BMA responds to Department of Health mental health workforce plans. BMA, London. https://tinyurl.com/ybtgxye8 (accessed 29 August 2017)

Department of Health (2017) Thousands of new roles to be created in mental health workforce plan. DH, London. https://tinyurl.com/y9akdjdr (accessed 31 August 2017)

Full Fact (2016) Unanswered questions on “extra £1 billion” for mental health. Full Fact, London. https://tinyurl.com/y7oyy8qc (accessed 1 September 2017)

Health Education England (2017) Stepping forward to 2020/21: The mental health workforce plan for England. HEE, Leeds. https://tinyurl.com/ycebebna (accessed 25 August 2017)

HM Treasury (2015) Spending Review and Autumn Statement 2015. The Stationery Office, London

The Labour Party (2017) Tory Government promising jam tomorrow when action is needed today to tackle the staffing crisis in mental health – Keeley. The Labour Party, Newcastle upon Tyne. https://tinyurl.com/y7db35pf (accessed 29 August 2017)

Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. NHS England, Leeds. https://tinyurl.com/gvc4or3 (accessed 25 August 2017)

NHS Employers (2017) NHS Employers welcomes plan to prioritise mental health services. https://tinyurl. com/ydg8h3ca (accessed 29 August 2017)

Prime Minister’s Office, 10 Down-ing Street, Department of Health, NHS England, The Rt Hon David Cameron, The Rt Hon Jeremy Hunt MP (2016) Prime Minister pledges a revolution in mental health treatment. Department of Health, London. https://tinyurl.com/z69jcpc (accessed 1 September 2017)

Royal College of Psychiatrists (2017) RCPsych response to HEE’s Mental Health Workforce Plan. RCPsych, London. https://tinyurl.com/yc2p93k8 (accessed 25 August 2017)

Royal College of Nursing (2017) RCN responds to Mental Health Workforce Plan. RCN, London. https://tinyurl.com/yavm3ulq (accessed 25 August 2017)

Royal College of Occupational Therapists (2017) Royal College of Occupational Therapists welcomes an expansion in the mental health workforce. RCOT, London. https://tinyurl.com/ycl9bss2 (accessed 25 August 2017)

UK Council for Psychotherapy (2017) We urge the Government to use existing therapist workforce to plug treatment gap. UKCP, London. https://tinyurl.com/ydfojrpk (accessed 29 August 2017)

Taken from British Journal of Mental Health Nursing, published September 2017.

Royal Pharmaceutical Society updates prescribing competency framework

Adobe Spark (1)The Royal Pharmaceutical Society (RPS, 2016) has published an update to the Competency Framework for all Prescribers to ensure health professionals prescribe safely and effectively.

Originally published in 2012, the framework was developed to offer a common set of competencies for prescribing, regardless of professional background. As a result, it is relevant to all prescribers, including doctors, pharmacists, nurses, dentists, physiotherapists, optometrists, radiographers, podiatrists and dietitians. However, the framework should be contextualised to reflect different areas of practice and levels of expertise.

Ash Soni, President of the RPS, said:

‘Both the number of medicines prescribed and the complexity of medicine regimens are increasing. The challenges associated with prescribing the right medicines and supporting patients to use them effectively should not be underestimated.

‘There’s lots of evidence to show that much needs to be done to improve the way we prescribe and support patients in effective medicines use. This guide will be invaluable and I’m delighted the RPS has coordinated the update.’

The initial framework was published by the National Prescribing Centre and the National Institute for Health and Care Excellence (NICE). For the update, the RPS was approached by NICE and Health Education England to carry out the work on behalf of all prescribing professions. Additionally, the RPS was asked to ensure the framework had UK-wide applicability.

A project steering group of prescribers across all professions and patients updated the framework. This involved a 6-week consultation of the draft policy, where hundreds of organisations and individuals responded.

The framework has been endorsed by the UK’s Chief Pharmaceutical Officers—Keith Ridge, Rose Marie Parr, Andrew Evans and Mark Timoney—who said:

‘The single competency framework provides a means for all prescribers to become equipped to support patients to achieve the best outcomes from their medicines.

‘This update will ensure individuals can continue to benefit from access to resources which help them continually improve their practice and work more effectively.

‘We commend the updated framework and encourage prescribers, professional bodies, education providers and regulators to use it to support their role in delivering safe and effective care.’

How the competencies are separated

The framework comprises 10 competencies split into two areas: the consultation and prescribing governance. Within each of these competency areas, statements describe the activity or outcomes that prescribers should be able to demonstrate.

The consultation

The first competency concerns assessing the patient. It promotes taking an appropriate medical, social and medication history, before undertaking an appropriate clinical assessment.

The second competency involves the prescriber considering the options for the patient. This includes both non-pharmacological and pharmacological approaches to treatment, and weighing up the risks and benefits to the patient of taking medicine.

The third competency is about reaching a shared decision with the patient/carer, so the patient/carer can make informed choices and agree on a plan that respects the patient’s preferences.

The fourth competency is the prescribing itself. The framework states the medicine should be prescribed only with ‘adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and unwanted effects.’ Where appropriate, medicines should be prescribed within relevant frameworks, such as local formularies or care pathways.

The fifth competency concerns providing information to the patient/carer about their medicines. This includes what the medicine is for, how to use it, possible unwanted effects and how to report them, and expected duration of treatment.

The sixth and final competency in the area of consultation is monitoring and reviewing. Here the prescriber should establish and maintain a plan for reviewing the patient’s treatment. The effectiveness of treatment and potential unwanted effects should be monitored.

Prescribing governance

The seventh competency, and first under the area of prescribing governance, concerns prescribing safely. It highlights that the prescriber should prescribe within their own scope of practice and recognise the limits of their own knowledge and skill.

The eighth competency comprises prescribing professionally, and ensuring the prescriber maintains confidence and competence to prescribe. This includes accepting personal responsibility for prescribing and understanding the legal and ethical implications.

The ninth competency focuses on improving prescribing practice through reflection. It also stresses the importance of acting on feedback and discussion.

The tenth and final competency involves prescribing as part of a multidisciplinary team to ensure continuity of care across care settings. Part of this concerns establishing relationships with other professionals based on understanding, trust and respect.

Putting the framework into practice

The framework can be used for a variety of reasons by prescribers to help them improve their performance and work more effectively. The following examples are highlighted in the framework:

  • To inform the design and delivery of education programmes; for example, through validation of educational sessions (including rationale for need) and as a framework to structure learning and assessment
  • To help health professionals prepare to prescribe and provide the basis for ongoing education and development programmes, continuous professional development and revalidation processes. For example, use as a framework for a portfolio to demonstrate competency in prescribing
  • To help prescribers identify strengths and areas for development through self-assessment, appraisal and as a way of structuring feedback from colleagues
  • To inform the development of education curricula and relevant accreditation of prescribing programmes for all prescribing professions
  • To provide professional organisations or specialist groups with a basis for the development of levels of prescribing competency; for example, from recently qualified prescriber through to advanced prescriber
  • To stimulate discussions around prescribing competencies and multidisciplinary skill mix at an organisational level
  • To inform organisational recruitment processes to help frame questions and benchmark candidates’prescribing experience
  • To inform the development of organisational systems and processes that support safe effective prescribing; for example, local clinical governance frameworks.

The RPS is liaising with the professional bodies and organisations of the other prescribing professions to encourage uptake of the framework, which will be reviewed again in July 2020.

References

Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers. http://www.rpharms.com/support-pdfs/prescribing-competencyframework.pdf (accessed 1 August 2016)

Taken from Nurse Prescribing, published 12 August 2016.

Association of Ambulance Chief Executives outlines strategic priorities for 2015/16

Paramedic prescribing and reform of paramedic education and training with Health Education England are among the key strategic priorities of the Association of Ambulance Chief Executives (AACE) for 2015/16.

The AACE National Programme, which is comprised of nine national groups and their respective 2015/16 work plans, as well as a number of other projects that are being progressed by the AACE with input from the national groups as required, is informed by its four strategic objectives: Ambulance Service: 2020 and beyond; Workforce, education and development; Operating model and efficiency; Clinical and patient safety.

The AACE aims to report on its ‘Ambulance service: 2020 and beyond’ project in May/June with an informed vision of what the ambulance service should look like beyond 2020 and suggestions to the ambulance sector on the steps and actions required to realise this vision.

Implementation of the Urgent and Emergency Care Review (U&ECR) will be an ongoing focus for the AACE in 2015/16, and will include the enhancement of NHS 111 services and reform of paramedic education and training with Health Education England.

Continued support and input will continue to the reform of paramedic education and training, with paramedic prescribing remaining a priority for the AACE to equip the profession for the ongoing expansion and diversification of the role.

The identification and development of future ambulance leaders is also a priority of the AACE, with focus being made on leadership development and consideration of a virtual academy and its potential for multidisciplinary training.

Ambulance service response will remain a focus for the AACE in 2015/16, and will include the development of future performance and clinical measures in light of the U&ECR, and the facilitation of any required changes to response protocol nationally following the completion of pilots in early 2015/16.

Finally, the AACE plans to deliver the National Ambulance Service Medical Directors’ Group’s Future National Clinical Priorities for Ambulance Services in England. Key clinical areas of focus include: emergency care; urgent care; mental health; the frail, elderly falls and dementia; long-term conditions; end of life patients; and public health and prevention.

To view the full list of strategic priorities, visit: http://aace.org.uk/national-programme/

Taken from Journal of Paramedic Practice, published 30 April 2015.