Sunday, 12 May 2013


Ignorance of tick-borne Lyme disease 'costing lives'

Areas of woodland can harbour ticks
When Joanne Drayson regularly walked her dogs in the woodland near her home in Guildford, Surrey, she was unaware that a tick the size of a poppy seed would infect her with a serious and debilitating disease.
"I had this strange symptom, which I can only describe as whole body rigidness. It kept recurring," she says.
Her health deteriorated to such an extent that she was unable to lift her legs or arms. The pain in her hips meant she was unable to climb stairs in her own home.
In the end, she was retired on health grounds from her job in the civil service.
Mrs Drayson now realises what happened to trigger the extreme fatigue, joint pain and stiffness that plagued her for more than four years.

What is Lyme disease?

Tell tale 'bullseye' rash after being bitten by a Lyme-infected tick
  • Lyme disease is a bacterial infection that is spread to humans by infected ticks.
  • The ticks that cause the disease are commonly found in woodland and heath areas, because that is where tick-carrying animals, such as deer and mice, live.
  • The most common symptom of Lyme disease is a pink or red circular "bull's-eye" rash that develops around the area of the bite.
  • Flu-like symptoms and fatigue are often the first noticeable signs of infection.
  • Diagnosed cases of Lyme disease can be treated with antibiotics, but if left untreated neurological problems and joint pain can develop months or years later.
In 2003, she remembers finding a tick on her foot, which caused a rash. At the same time she had flu-like symptoms that lasted several weeks.
When Mrs Drayson was bitten again two years later, she developed symptoms similar to arthritis, but doctors still did not suspect that the ticks had infected her with Lyme disease.
"I had removed ticks from my dogs for over 30 years, but didn't really know much about them.
"There are probably thousands of people who could end up like me."
Devastating impact
It was 2007 before she was given a clinical diagnosis, after her GP prescribed antibiotics for a chest infection and they dramatically improved her symptoms.
This weekend, a group of individuals calling themselves Worldwide Lyme Protest UK is highlighting the devastating impact of Lyme and other tick-borne diseases when they are misdiagnosed.
Nicola Seal, from Aberdeen, who has co-ordinated the UK protest, says the disease is not understood by the vast majority of medical professionals, leaving thousands of patients without the appropriate treatment.
"We wanted to put our personal stories to the Department of Health to make them aware that people are dying because they are not getting diagnosed and treated properly."
She adds: "There is a lack of GP experience and knowledge - and when people are diagnosed with Lyme disease, we lack any professionals who understand it."

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So many people are going undiagnosed because the tests are not foolproof”
Stella Huyshe-ShiresLyme Disease Action
The protest group is also urging the government to re-examine the current NHS test for Lyme, which it says misses as many as two-thirds of genuine cases.
Official estimates put the number of new UK cases each year at around 3,000, but Lyme disease charities say the figure could be as high as 15,000 annually because so many people do not have their condition diagnosed.
Stella Huyshe-Shires, who chairs the charity Lyme Disease Action, says that patients have not been listened to in the past and this has created a problem.
"So many people are going undiagnosed because the tests are not foolproof. The test relies on detecting antibodies which may take weeks to appear in some people.
Patients going abroad
"They may may not even develop the antibodies which the test looks for."
She says the NHS is not at fault. It is simply that the test is not perfect.
The result is that patients go abroad to private clinics to look for a test that will prove they have Lyme disease, spending a lot of money in the process.
At the Rare and Imported Pathogens Laboratory in Wiltshire, where tests for Lyme disease are carried out, a two-tier testing system recommended by American and European authorities is used.
Public Health England, which runs the lab, says the tests are sensitive enough to detect low levels of antibodies, occasionally producing a false positive result.
A deer tick which feeds on human blood and can cause Lyme DiseaseDeer ticks feed on human blood and can cause Lyme disease infection
It also acknowledges that the antibody response takes several weeks to reach a detectable level, so tests in the first few weeks of infection may be negative.
Dr Tim Brooks, head of the Rare and Imported Pathogens Laboratory, says they are always looking to improve their diagnostic systems.
"The laboratory is evaluating different diagnostic tests, and will be developing a specific set of guidance for the investigation and management of Lyme disease in the UK."
Yet there are still many uncertainties surrounding Lyme disease, says Mrs Huyshe-Shires.
By bringing clinicians and patients together, the charity has published a list of "unknowns" in the diagnosis and treatment of Lyme disease, which it hopes will inform any future research and guidance.
One controversial issue concerns the treatment of borreliosis, caused by the Borrelia burgdorferi bacterium, the agent of Lyme disease.

Where do ticks live?

Tick feeding on a human leg
  • Ticks can survive in many places, but prefer moist areas with dense vegetation or long grass.
  • Ticks are most active between spring and autumn.
  • Ticks prefer warm moist places on your body,
While most doctors agree that treatment of this type of infection with oral antibiotics in its early stages is often successful, there is far less agreement regarding the treatment of chronic Lyme disease, which keeps recurring because of a delayed diagnosis.
In these cases, a more lengthy course of intravenous antibiotics may be required. There is also the possibility that patients may relapse after a lengthy remission.
BADA UK, Borreliosis and Associated Diseases Awareness UK, says a full recovery is not certain.
"The length of time a person has been infected before treatment, whether the patient has been given sufficient treatment, and whether there are co-infections present, can all have a big impact on a patient's recovery," it says.
Much more study into the nature of the Borrelia bacterium needs to be done before a safe and reliable vaccine for all the strains can be created, BADA UK says.
Helpline for doctors
The Department of Health has been working closely with Public Health England and NHS England to raise awareness among doctors and nurses. It says it is using the latest world-class diagnostic tests to look for the disease in patients with symptoms.
There is now a Lyme disease helpline that doctors can call if they spot symptoms and are unsure about what to do.
Six years on from her diagnosis, Mrs Drayson's health has changed for the better after a long course of antibiotics.
"I've recovered my health and my life. I can now cycle and run upstairs."
But she says no two people react in the same way to Lyme disease.
"We have to acknowledge that people react in a different way to different treatments. There is no definitive treatment. We have to give patients the opportunity to have ongoing treatment if they need it."

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Sunday, 5 May 2013

Essential standards of quality and safety


Essential standards of quality and safety
The essential standards of quality and safety consist of 28 regulations (and associated outcomes) that are set out in two pieces of legislation: the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

 For each regulation, there is an associated outcome – the experiences we expect people to have as a result of the care they receive.

 When we check providers’ compliance with the essential standards, we focus on the 16 regulations (out of the 28) that come within Part 4 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 – these are the ones that most directly relate to the quality and safety of care. Providers must have evidence that they meet the outcomes.

 These 16 regulations are set out below. (Note that the outcome numbers are different to the regulation numbers because we have grouped the outcomes into six overall themes. See our Essential standards of quality and safety publication for full details.)

 Regulation* Outcome Title and summary of outcome
9 4 Care and welfare of people who use services
People experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.
10 16 Assessing and monitoring the quality of service provision
People benefit from safe, quality care because effective decisions are made and because of the management of risks to people’s health, welfare and safety.
11 7 Safeguarding people who use services from abuse
People are safeguarded from abuse, or the risk of abuse, and their human rights are respected and upheld.
12 8 Cleanliness and infection control
People experience care in a clean environment, and are protected from acquiring infections.
13 9 Management of medicines
People have their medicines when they need them, and in a safe way. People are given information about their medicines.
14 5 Meeting nutritional needs
People are encouraged and supported to have sufficient food and drink that is nutritional and balanced, and a choice of food and drink to meet their different needs.
15 10 Safety and suitability of premises
People receive care in, work in or visit safe surroundings that promote their wellbeing.
16 11 Safety, availability and suitability of equipment
Where equipment is used, it is safe, available, comfortable and suitable for people’s needs. 
17 1 Respecting and involving people who use services
People understand the care and treatment choices available to them. They can express their views and are involved in making decisions about their care. They have their privacy, dignity and independence respected, and have their views and experiences taken into account in the way in which the service is delivered.
18 2 Consent to care and treatment
People give consent to their care and treatment, and understand and know how to change decisions about things that have been agreed previously.
19 17 Complaints
People and those acting on their behalf have their comments and complaints listened to and acted on effectively, and know that they will not be discriminated against for making a complaint.
20 21 Records
People’s personal records are accurate, fit for purpose, held securely and remain confidential. The same applies to other records that are needed to protect their safety and wellbeing.
21 12 Requirements relating to workers
People are kept safe, and their health and welfare needs are met, by staff who are fit for the job and have the right qualifications, skills and experience.
22 13 Staffing
People are kept safe, and their health and welfare needs are met, because there are sufficient numbers of the right staff.
23 14 Supporting workers
People are kept safe, and their health and welfare needs are met, because staff are competent to carry out their work and are properly trained, supervised and appraised.
24 6 Cooperating with other providers
People receive safe and coordinated care when they move between providers or receive care from more than one provider.
* Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
The other 12 regulations relate more to the routine day-to-day management of a service. The information we receive in respect of these helps us to check that the service is being run appropriately and responsibly, and to monitor generally the provider’s compliance with the essential standards of quality and safety. However, we will make checks where concerns are raised with the 12 regulations.

 Regulation Outcome Title and summary of outcome
4* 22 Requirements where the service provider is an individual or partnership
People have their needs met because services are provided by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
5* 23 Requirement where the service provider is a body other than a partnership
People have their needs met because services are managed by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
6* 24 Requirements relating to registered managers
People have their needs met because services have registered managers who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
7* 25 Registered person: training
People have their needs met because services are led by a competent person who undertakes the appropriate training.

12** 15 Statement of purpose
People know that the Care Quality Commission is kept informed of the services being provided.
13** 26 Financial position
People can be confident that the provider has the financial resources needed to provide safe and appropriate services.
14** 27 Notifications – notice of absence
People can be confident that, if the person in charge of the service is away, it will continue to be properly managed.
15** 28 Notifications – notice of changes
People can be confident that, if there are changes to the service, its quality and safety will not be affected.
16** 18 Notification of death of a person who uses services
People can be confident that deaths of people who use services are reported to CQC so that, if necessary, action can be taken.
17** 19 Notification of death or unauthorised absence of a person who is detained or liable to be detained under the Mental Health Act 1983
People who are detained under the Mental Health Act can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
18** 20 Notification of other incidents
People who use services can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
19** 3 Fees
People who pay for services know how much they are expected to pay, when and how, and what service they will get for the amount paid.
* Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
** Regulation of the Care Quality Commission (Registration) Regulations 2009
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Staff should help residents to eat


06 February 2009 today there is a crisis @ Ivybank care home ,lack of food,and the staff have problems with the 
heating and they have not got the keys nor anyone to deal with the problem,i.e. it is very cold today.
John a member of staff @ Ivybank expressed that to me on the phone today, to help he is going to on my
request try and get my mother a take away meal delivered to her she will pay. 
I was unable to obtain a reply from 0117 956 7890 begbrook office , however I have spoken to your office and 
the lady I spoke to is aware of the above and was setting about dealing with this matter , I myself will
be doing all that is neccesary to help the situation within Ivy bank House.

  Living in a Care Home 
Food & mealtimes 
Food preparation and the rituals of eating are important elements of cultural identity. Involving residents in planning and preparation and helping residents to enjoy their food wherever possible is a sign of a home that takes the concept of holistic care seriously – caring for the whole person rather than a collection of ailments and illnesses. 
Food is, of course, essential to physical wellbeing and enabling residents to eat well is an important part of the job of care staff. Residents should have access to three meals a day and drinks and snacks in between. Thought should be given to the timing of meals with care taken to avoid big gaps particularly between supper and breakfast. If the evening meal is quite early then what is offered for supper would have to be quite substantial to take the resident comfortably through to breakfast. And it is important that residents are offered snacks and drinks. Staff should not rely on residents to ask as shyness, confusion or not wanting to bother staff may leave residents hungry or thirsty. 
A helping hand 
Staff should help residents to eat. They should not feed residents. The difference may be difficult to judge but it is an important one. Sitting next to the resident, maintaining eye contact, talking to the resident and going at their pace are all indications that the carer is helping rather than feeding. Carers should never be helping more than one resident at a time. Nor should they be talking to a co-worker or watching TV while they are doing it. 
Going alone 
After perhaps years of living alone or with a partner, getting used to communal eating may be difficult. It is common for residents to withdraw to their rooms and take all their meals there. Staff may try to 
persuade your relative to join their fellow residents in the dining room. Although it is good to encourage residents out of their isolation, and try to address any reasons why residents may be reluctant to eat with others, ultimately the wishes of the resident must be respected. Residents must not be forced or coerced into changing their behaviour. 
Private space 
Eating with other people may become something of an endurance test and source of anxiety that could lead some people to withdraw from being with others as the only way of maintaining their dignity. When residents exercise their choice to stay in their room, for meals they have previously taken in the dining room with other residents, it may be worth thinking about what has caused this. It may have been an embarrassing episode – difficulty in eating, a row with another resident or member of staff, or failure to get to the toilet in time – that has caused a change in behaviour. 
Remember 
• A resident’s likes and dislikes should be recorded in their care plan and reviewed regularly. 
• Food should be attractive, even if is liquidised. 
• Discuss any problems your relative is having with eating with their key worker, the cook or the home manager 
• If food is prepared or served in an unusual way ask why such steps are necessary and how the decision was reached. 
• When helping a resident to eat, staff should sit, maintain eye contact and go at the resident’s pace. 
• Drink should never be withheld from a resident in response to incontinence. It is likely to make matters worse. 
At the care meeting nobody except Michelle Totanes spoke about mothers food and the filth she has been served, she is vegetarian, when I stated this at the meeting
Michelle Totanes stated that my mother was not a vegetarian , why,?First incident with michelle I received call
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NHS Wales staff survey: Only 52% happy for family treatment


NHS Wales staff survey: Only 52% happy for family treatment

The findings of an NHS staff survey also show that a third of workers have been ill with stress in the past year

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Only 52% of NHS employees in Wales would be happy with the standard of care provided by the health service if a friend or relative needed treatment.
The findings of an NHS staff survey also show that a third of workers have been ill with stress in the past year.
But it also found staff are highly dedicated, with more than four in five saying they would be willing "to go the extra mile" for the organisation.
Health Minister Mark Drakeford said the survey showed a "mixed" picture.

“Start Quote

I think it does reflect the sense of a service which it knows it is under pressure and not able to do a job that people would like it to be done”
Mark Drakeford AMHealth Minister
"It isn't satisfactory that just over half of people working in our NHS positively think that what they provide would be good for somebody in their family," he said.
"It's a finding that's consistent with other parts of the NHS across the United Kingdom and I think it does reflect the sense of a service which it knows it is under pressure and not able to do a job that people would like to be done."
Mr Drakeford said some staff felt under strain and that the survey showed a "disconnect" between managers and employees on the front line. He was also concerned about scepticism among staff that their views will be acted on.
He said: "My job is to make sure this survey is used and pursued, and that local managements take it seriously and respond to it."
The survey is the first to be carried out in six years with 22,392 staff working in the Welsh NHS filling it out, representing 27% of the workforce.
It found 64% of NHS staff who responded said they were satisfied with their current job but fewer than half would recommend the NHS as an place to work.
A third of staff said they had been injured or felt unwell because of stress in the last 12 months and just under half (48%) felt they did not have enough time to complete their work.

“Start Quote

There are some very clear positives... showing that the workforce are committed and want to deliver a quality service.. however, there are some concerning elements of the survey and it is essential that these elements are addressed ”
Dawn BowdenUnison
Work related stress was highest amongst ambulance technicians (65%), paramedics (62%) and ambulance control staff (45%).
The survey responses also suggested that issues of bullying harassment and violence affected a small but notable minority of health service staff.
The Royal College of Nursing (RCN) in Wales and Unison - the union that represents many NHS staff - welcomed the survey's publication but called for action to address some of the concerns.
Peter Meredith-Smith of RCN Wales said the survey would only be beneficial if concerns were addressed.
He added: "Although the headline findings are in many respects positive, close reading of the national report indicates an NHS in Wales that is under significant pressure. It is apparent that frontline clinical staff are bearing the burden of that pressure.
Dawn Bowden, head of health at Unison Cymru Wales, said it was important to gauge how morale and workload pressures are among NHS staff.
'Matter of concern'
She said: "There are some very clear positives coming out of the survey results, showing that the workforce are committed and want to deliver a quality service.

“Start Quote

While this survey reflects much that is good in NHS Wales from the perspective of the frontline staff who work in it, clearly there is much to be done to change some of the unacceptable cultural norms”
Dr Richard LewisBritish Medical Association
"However, there are some concerning elements of the survey and it is essential that these elements are addressed in order to ensure that this staff survey is a meaningful exercise for the workforce and patients."
Dr Richard Lewis, Welsh secretary of the British Medical Association, added: "While this survey reflects much that is good in NHS Wales from the perspective of the frontline staff who work in it, clearly there is much to be done to change some of the unacceptable cultural norms."
The survey also indicated significant problems within the Welsh Ambulance Service.
Ambulance staff reported the lowest level of job satisfaction of any group in the NHS and a relatively high level of concerns in several categories.
They include the lowest levels of job engagement, the highest levels of stress, and higher levels of dissatisfaction with managers. Paramedics were also least happy about the standard of care being delivered.
Mr Drakeford called it "a matter of concern".
Last week a wide ranging review into the ambulance service highlighted problems with staff morale and recommended big changes to the way it is run.
The review will be debated by Welsh assembly members on Tuesday.

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Care home companies face tougher financial checks


Care home companies face tougher financial checks

Nadra Ahmed, National Care Association: "It's not just the top 50 we need to look at"

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Large providers of care homes in England are to have their financial records regularly scrutinised in future to spot potential business problems.
Under the government's plans, the Care Quality Commission and local authorities will also ensure care continues if a company does go bust.
It comes after provider Southern Cross collapsed, causing distress and anxiety to its residents and their families.
Care minister Norman Lamb said the move would give reassurance to people.
The Care Quality Commission (CQC) will start to make checks on between 50 and 60 of the largest care companies in England, including those that provide care in a person's home.
CQC chief executive David Behan said the measures - to be set out in new legislation - would provide early warning of potential company failures in the care industry.
The CQC will have the power to:
  • Require regular financial and relevant performance information
  • Make the provider submit a "sustainability plan" to manage any risk to the organisation's operation
  • Commission an independent business review to help the provider to return to financial stability
  • Get information from the provider to help manage a company collapse
The Department of Health said the powers would bring care in to line with other services such as hospitals and holiday operators, which have procedures to check on the "financial health" of organisations.

“Start Quote

The fear and upset that the Southern Cross collapse caused to care home residents and families was unacceptable”
Norman LambCare and Support Minister
In the case of the collapse of a national provider the effects would be felt in many parts of the country, so it would be unfair for local councils to have to deal with the problem, the department said.
Mr Lamb said: "Everyone who receives care and support wants to know they will be protected if the company in charge of their care goes bust.
"The fear and upset that the Southern Cross collapse caused to care home residents and families was unacceptable.
"This early warning system will bring reassurance to people in care and will allow action to be taken to ensure care continues if a provider fails."
Southern Cross, the country's biggest care provider, had thousands of elderly residents at more than 750 care homes across the UK when it collapsed in 2011.
The firm was brought down by having to pay a £250m rent bill as local authorities made cuts.
After its collapse, other operators had to step in to take over the care of more than 30,000 people.
BBC social affairs correspondent Michael Buchanan said in that case nobody had to leave their care home because other companies took them over, but the government has been keen to ensure such a collapse is not repeated.
A report earlier this week said the number of care homes going bust had almost doubled in the past two years, with the level of fees that local authorities were willing to pay being blamed.

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Friday, 3 May 2013

MMR jab: Somali migrants have lingering fears on autism


MMR jab: Somali migrants have lingering fears on autism

By Melanie AbbottRadio 4's The Report
A measles vaccination kit

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Health officials say vaccination rates against measles are worryingly low among Somali children in the US and UK because some parents still believe the MMR jab is linked to autism.
The officials say they are struggling to show that the vaccination is safe.
BBC Radio 4's The Report has found that the discredited former doctor Andrew Wakefield visited some Somali groups in the US.
Health authorities there blame him for the drop-off in MMR vaccinations.
Andrew Wakefield, who now lives in Texas, says Somalis in Minnesota already had fears about autism and MMR before his visit.
Somali Bakita Mohamed Haji lives in north-west London with her 10-year-old daughter, who suffers from autism.
Fears reinforced
She says her daughter's condition started after she was given the jab.
"My daughter was born normally but when I started the MMR, my daughter changed. Screaming all the time, crying. I went to the hospital and they said it's autism. I don't understand it. I'd never heard of it."

“Start Quote

A number of individuals reached out to the community who planted the seed that there might be concerns about vaccination”
Kristen EhresmannMinnesota department of health
She wishes her daughter had never had the injection, which she believes caused the condition.
Health experts say her fears, and those of other parents, have been reinforced by a common belief in their community that only the children of Somali families that emigrate to the West develop autism, whereas those who stay at home do not.
While there is no solid evidence to confirm this, a small study of immigrants in Stockholm, the Swedish capital, did suggest that families using services for autistic children were more likely than expected to be from West and East Africa.
Discredited study
And separate research in the UK also found there was a higher than average incidence of autism in children born to African mothers - but it did not establish a reason why.
The fears of Somali parents echo those sparked by a study in The Lancet medical journal that linked MMR with autism.
The study was discredited and withdrawn. Andrew Wakefield, the lead author, was struck off by the General Medical Council because of ethical concerns about his methods.

FIND OUT MORE

Coloured Transmission Electron Micrograph of a section through a human cell infected with the measles virus
For more details of how to listen again, go to The Report website.
A subsequent raft of research has found no link between the MMR vaccine and autism, and average vaccination rates are back up to 94% in England for five-year-olds receiving the first dose of MMR.
Parents frustrated
But take-up of the vaccine is much lower among Somali children in the UK and in the US.
In Minnesota in the Midwest, the Somali American Autism Foundation has pledged to find out what causes the condition in their children.
Idil Abdul runs the foundation and has a son, 10, who is autistic.
"If your child is sick, the goal is you take them to the doctor and the doctor tells you what's wrong with the kid and how to make him better. With autism, we go to the doctor and they say, 'We don't have a cause, we don't have a cure, too bad, so sad, you might not get access to early intervention, have a nice day.'"

“Start Quote

It is very difficult to dislodge beliefs from whatever community if they're dealing with a disease that isn't adequately explained”
Prof David SalisburyDirector of immunisation at the Department of Health
She does not believe there is a link between MMR and autism but says parents are frustrated because they do not feel their concerns are being listened to by the authorities.
'Planted the seed'
Andrew Wakefield visited Minnesota at least three times between 2010 and 2011, promising research to find answers to their questions.
The Minnesota department of health says his visit contributed to a drop-off in MMR uptake among Somalis and says only around 50% of Somali children now receive the vaccine.
Kristen Ehresmann, the state's director of infectious disease, believes he had an influence on Somali perspectives.
"There were a number of individuals who reached out to the community who planted the seed that there might be concerns about vaccination and what role it could play.
"Since that time we've seen vaccination rates drop off accordingly."
Andrew Wakefield denies his visit caused the drop in Somali children having the MMR jab, claiming the trend was already happening.
'Vaccination champions'
He said: "The reason that I was invited was to help address the Somalis' pre-existing fears about developmental regression in their children following MMR immunisation."
Although there are no official statistics, vaccination rates are also believed to be low among Somali children in London.
Shukri Osman, a parent of an autistic child, estimates that only half the Somali parents she knows have taken up the vaccine.
And in Brent, the area in north-west London where she lives, the council says low uptake in the Somali community has been recognised for a number of years.
It is currently training up "community vaccination champions" and now has an immunisation team with Somali-speakers.
Engrained perceptions
Prof David Salisbury, the director of immunisation at the Department of Health, said: "We know that there is not an association between MMR and autism, and that I'm sure has been said many times to Somali community leaders."
But even he admits it will be hard to change what may have become engrained perceptions.
"I think we know it is very difficult to dislodge beliefs from whatever community if they're dealing with a disease that isn't adequately explained on the basis of the cause. "
You can listen again to The Report on BBC Radio 4 via the Radio 4 website or The Report download.

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