Patients' taxis cost NHS millions

Patient transport services are mainly run by ambulance trusts

More than £30m has been spent on taxis for NHS patients since 2008 because of a shortage of official non-emergency transport, the BBC has learned.

The figures cover the transfer of patients who are too ill to travel by themselves, such as those with broken limbs or receiving chemotherapy.
Ambulance trusts in England, Wales and Northern Ireland responded to a BBC Freedom of Information request.
Health chiefs insisted the practice was not putting patients at risk.
But they admitted they were aiming to reduce the use of taxis amid concerns that their use was not providing value for money.
The North West Ambulance Service has spent the most on taxis - £9.9m since April 2008, on more than 500,000 journeys. However, like many trusts it said it was in the process of reducing its reliance on them.
Some trusts also provided information on the most costly taxi journeys they had paid for.
These included two fares in excess of £700. One was for a 184-mile journey from Cambridgeshire to Bristol when a patient was discharged from Papworth Hospital, while the second was for a 151-mile trip from Chase Farm Hospital in north London to Shrewsbury, Shropshire.
Regular use
Patient transport services - provided free to those who are too ill or unable to travel to and from hospitals - are mainly run by ambulance trusts, although private firms are used in some places.

Costly taxi journeys

• East of England Ambulance Trust paid £777.45 for a 184-mile journey from Cambridge to Bristol when a patient was discharged from Papworth Hospital
• The service in London paid £747 for a 151-mile journey from London's Chase Farm Hospital in north London to Shrewsbury in Shropshire
• £670.86 was handed over for a 290-mile journey from St Cross General Hospital in Rugby to a nursing home in Falmouth by West Midlands ambulance bosses
• About £600 was paid for a 262-mile journey from Queen Elizabeth Hospital in Greenwich to Hartlepool by London's ambulance service

The services rely on specially adapted vehicles - normally minibuses equipped with basic medical supplies such as oxygen - staffed by trained crews to ferry patients around.

For those who do not need any medical assistance, official ambulance trust cars can be used to drive them.
But when neither of these options are available, they have to turn to private taxi companies.
Only the South East Coast Ambulance Trust has avoided paying anything out to taxis in the past three years, while London has reduced its reliance on them to under 100 journeys a year.
The figures show that all other ambulance trusts use taxis on a regular basis.
Value for money
Sara Gorton, from Unison, expressed concern about taxi use.
"There may be occasions where it is unavoidable, but while these are not patients who have dialled 999, there will be times when they will need someone with more skills and training than just how to drive.

Case study

The North West Ambulance Service is one of the largest providers of patient transport services in the NHS so in many ways it is not surprising that it spends the most on taxis.
Since April 2008 it has paid out nearly £10m on more than 500,000 journeys.
But in recent years its reliance on taxis has been falling. Latest figures show 6% of transfers were done by taxi - down from 10% in previous years.
This has been achieved through an overhaul of the way the service works.
Patient transport was given its own dedicated management structure two years ago. Before that there was a joint structure with the emergency side of the trust.
Working hours have also been altered to move the service from what was a largely 8am to 6pm operation to one more geared towards round-the-clock working.

"But our concerns about [patient transport services] go wider than use of taxis. There are big differences in the way that patient transport is provided and what standards are kept to in different areas.

"Increasingly, services are being outsourced to private firms which means that competition is based on costs, and standards are being driven down. This also means it's harder to find out what is happening."
But Delwyn Wray, the director of patient transport services at North West Ambulance Trust and vice-chairman of the National Patient Transport Service Group, said while there was concern about taxi use, it was on value-for-money grounds rather than safety.
"Anyone needing medical help in any way would not go by taxis."
But he added: "I think there will always be a need for them at times, but each service needs to look at how they are using them and whether there is a more efficient and better way of transporting patients. That is what we are gearing up to in the North West."
The Department of Health said it was up to local NHS chiefs to decide about who transported patients.
Data for how much was spent on taxis in Scotland was not available.

babies

“Babies born weighing less than 4lb (1.8kg) could be more prone to developing autism

http://www.westof.eu/healthy/page22.html

Monday October 17 2011

Most children with autism have a normal birthweight

“Babies born weighing less than 4lb (1.8kg) could be more prone to developing autism than children born at normal weight,” BBC News has reported.
This finding comes from a study that found about 5% of infants whose birthweight was less than 2000g (about 4lbs and 6oz) had autistic spectrum disorders (ASDs) at the age of 21. This was higher than previous estimates that suggested that 0.9% of US eight year olds of any birthweight have been diagnosed with some form of ASDs.
The main limitation to this study is that it did not include a control group of children with normal birthweight to compare against those with low birthweight. Instead, it relied on general population estimates to examine the relationship. This makes understanding the issue more complex as the children in this study were all given specific assessments for detecting ASDs that would not be routinely given to children in the general population.
This means we cannot be certain to what extent children with low birthweight truly do have higher rates of ASDs or if the methods used simply detected cases that would go undiagnosed in everyday life. This is supported by the fact that some of the cases identified had not previously been diagnosed by a doctor.
It is also worth noting that a large proportion of those eligible to participate did not complete the study and this may have influenced results. Overall, the findings of this study need to be confirmed by more robust studies with a control group of infants of normal birthweight.

Where did the story come from?

The study was carried out by researchers from the University of Pennsylvania and other research institutes in the US. It was funded by US National Institutes of Health and published in the peer reviewed medical journal Pediatrics.
BBC News generally placed the study into context well, noting that the findings need to be confirmed in other studies and including quotes such as those from Dorothy Bishop, professor of developmental neuropsychology at the University of Oxford. She is quoted as saying, 'the association looks real, but nevertheless, most low birthweight children don't have autism, and most children with autism don't have low birthweight'.

What kind of research was this?

This was a prospective longitudinal study that looked at what proportion of infants with low birthweight went on to develop autistic spectrum disorders (ASDs) in adolescence or early adulthood.
ASDs, including autism and Asperger’s syndrome, and are a group of related disorders that begin in childhood and persist into adulthood. They are diagnosed by the presence of three broad categories of symptoms:

• difficulties with social interaction
• impaired language development and communication skills
• unusual patterns of thought and physical behaviour

In over 90% of cases no underlying medical condition can be found to explain the symptoms of ASD, though causes continue to be investigated.
The researchers say that low birthweight is an established risk factor for cognitive and movement problems, and some studies have suggested that low birthweight may also be a risk factor for ASDs. However, they also point out that most prospective studies examining this possible association have not made firm diagnoses of ASDs using standard diagnostic methods.
This study followed only a group of low birthweight individuals, and then made comparisons with how common autism is in the population as a whole, based on the figures reported in another study. This may give some idea of whether autism is more common in low birthweight infants but there are some limitations. For example, the children in this study were given assessments to specifically test whether they had autism, which means that more cases might be picked up than would be found than in the general population, which is not routinely screened for autism.
Ideally, the study would have included groups of babies with different birthweights all born in the same period, and followed and assessed them in the same way. This could help establish whether the results seen would be genuinely due to increased prevalence or due to increased diagnosis. It would also allow them to take into account any other differences between babies of low and normal birthweights.

What did the research involve?

The researchers enrolled 1,105 low birthweight infants who weighed less than 2000g when they were born. Babies born between October 1, 1984 and July 3, 1989, at three New Jersey hospitals were eligible. Of these infants, 862 (78% of those enrolled) were eligible for follow-up at age 16, and 623 (56%) were screened to identify those that might have ASDs. At age 21, the researchers used standard diagnostic interviews for ASDs to reassess 60% of those who screened positive for autism at age 16, and 24% of those who tested negative. This confirmed which individuals had a diagnosis of ASDs. They used the figures to estimate how common autism was in the entire group of low birthweight babies.
The infants in this study were part of the Neonatal Brain Hemorrhage Study (NBHS), which included all infants admitted to three hospitals in New Jersey, which cared for 85% of low birthweight babies born in the area. The children were assessed at ages 2, 6, 9, 16, and 21 years. At age 16, this included questionnaires that the parents completed about autism symptoms and social communication. The questionnaires asked parents if their child had ever been diagnosed with ASDs by a healthcare professional.
The ASDs the researchers tested for included autism, Asperger’s syndrome, or a pervasive developmental disorder (not otherwise specified). Those scoring over set thresholds on the questionnaires or those with a professional ASD diagnosis were considered to be ‘screen positives’, and assessed again for a ASDs diagnosis at age 21.
The researchers also tested a proportion of adolescents who had screened negative at 16 to identify whether the initial screening had missed any cases. The diagnostic interviews at age 21 were conducted with the parents and with the young adult themselves, and were performed by researchers who did not know whether the participants had screened positive or negative for ASDs at age 16.

What were the basic results?

In the first ASDs screen at age 16 years, 117 low birthweight adolescents (18.8% of those tested) screened positive for ASDs. Of these 117 adolescents, 47 (40.2%) were lost to follow-up or did not complete the ASD questionnaires at age 21. Of the 70 who were assessed at age 21 years, 11 (15.7%) were confirmed as having ASD at age 21.
In the first ASD screen at age 16 years, 506 (81.2%) low birthweight adolescents had screened negative for ASDs. Of these 506 adolescents, 119 (23.5%) were selected for assessment at age 21. Of these 119 screen negatives, three (2.5%) were found to have ASD at their later assessment.
Most of the participants identified with ASDs (9 out of 14) were reported to have relatively high levels of functioning, spoken language, and with IQs of 70 or over.
Based on these figures, and the proportion of screen positives and screen negatives at age 16, the researchers calculated that about 5% of the entire low birthweight cohort assessed at age 16 had ASD. Just over half of these young adults (8 out of 14) had not been diagnosed prior to this study.
There were some differences between the individuals who could be followed up and those who could not. For example, those who were not followed up at age 21 were more likely to have had suboptimal neurodevelopmental outcomes at age 16 (for example, cognitive or movement disabilities).

How did the researchers interpret the results?

The researchers conclude that ASDs in this group of low birthweight individuals was 5%. They say that this was higher than the prevalence of 0.9% reported by the US Centers for Disease Control and Prevention for eight year olds in the general US population (all birthweights) in 2006.

Conclusion

This study has suggested that about 5% of children of low birthweight (<2000g) in the US may go on to develop autistic spectrum disorders (ASDs). This is higher than previous estimates for the general population of children in the US (estimated at 0.9% among eight year olds). When considering these results there are both strengths, such as the prospective nature of the study, and limitations that must be taken into account:

• The children in this study were specifically assessed to see if they had autism, which means that more cases might be picked up than would be found than in the general population, who are not all assessed for autism. Ultimately, this raises the question of whether the results reflect greater prevalence among underweight babies or greater rates of diagnosis. Ideally, the study would have included a group of babies of different birthweights all born in the same period, and followed them all up and assessed them in the same way. This would also allow them to take into account any other differences between low birthweight and normal birthweight babies that could influence rates of ASDs.
• The general population prevalence figures were based on children aged eight, and these figures may differ from those found among adolescents and young adults such as those in this study.
• A high proportion (40%) of those assessed at age 16 could not be assessed again at age 21, and this could have influenced the results.
• Not all participants received all parts of the screening and diagnostic assessments.

The results of this study need to be confirmed by more robust studies with a control group of infants with normal birthweight. It is also worth bearing in mind the quote from Dorothy Bishop, professor of developmental neuropsychology at the University of Oxford, in the BBC News: 'The association looks real, but nevertheless, most low birthweight children don't have autism, and most children with autism don't have low birthweight.'

Links to the headlines

Low birthweight 'linked to autism', says US study. BBC News, October 17 2011

“Trendy fish pedicures; the risk of catching a virus are 'very low'

Tuesday October 18 2011

The risk of catching a virus are 'very low'

“Trendy fish pedicures could spread HIV and hepatitis C,” The Sun has today reported. Its front-page story said that officials have raised an “alert” over the treatment, popular in beauty spas, where tiny fish are used to nibble away areas of hard foot skin.
While The Sun has been carping on about warnings and alerts, the newspaper seems to have overestimated the scale of the risk, which health experts have described as being “extremely low”. Rather than being an alert, the news is based on a report by the Health Protection Agency that has set out good practice for so-called ‘fish spas’ that offer the service.
While the report did acknowledge that the risk of infections could not be completely ruled out, it is important to view this in context and not be reeled in by fishy headlines.

What exactly is a fish pedicure?

A fish pedicure is a beauty treatment that uses dozens of tiny fish to nibble away dead and hardened skin from the feet. During a session a person immerses their feet in a tank of warm water and lets the minute, toothless Garra rufa fish nibble away for around 15 to 30 minutes. The fish are said only to eat dead skin, although there are some anecdotal reports that they can break the skin if they nibble too deep.
Fish pedicures have long been used as beauty treatments in Turkey and the Far East, but have only recently been introduced to this country. In the few years since the first UK ‘fish spa’ opened the treatment’s popularity has rocketed due to celebrity endorsements and high-profile press coverage. The HPA says that, as of spring 2011, it is aware of 279 in operation (although there are likely to be many more).
A small number of spas may also be using other species of fish to perform pedicures, such as Chin chin fish. However, the HPA says that these should not be used as they develop teeth when they get older, and may therefore present a greater risk to public health.

What did the report examine?

The report examined a number of issues relating to fish pedicures, including:

• potential ways infections might occur
• the risk of catching blood-borne viruses, including HIV and hepatitis
• the risk of bacterial infections
• the risk of catching parasites, such as fluke worms
• the risk of transmitting conditions, such as athlete’s foot and verrucas
• procedures that might reduce any health risks

The report is based on consultations with experts and professional bodies within the fields of public health, aquaculture, health and safety, and animal welfare.

What did the report find?

The report considered three main ways that a person might catch an infection:

• from a fish or a fish tank
• from tank water
• from another person via surfaces, such as floors

Within these areas they considered the different types of infections that might occur.
Blood-borne viruses
Viruses such as HIV and hepatitis are carried in the blood and, in theory, could be transmitted through tank water if someone with a cut or abrasion were to use a tank containing traces of blood from an infected person with cuts.
However, there is only anecdotal evidence that Garra rufa fish can draw blood, and the HPA says that any blood-borne viruses they come into contact with are unlikely to stay on the surface of their mouths and lead to infection. Any blood entering the tank is likely to be diluted by the volume of water used.
While transmission through this method cannot be completely ruled out, the HPA says the risk of catching a blood-borne virus in this way is extremely low. Further to this, the HPA is recommending that the fish spas check clients for cuts and abrasions both before and after their session.
Parasites
Fish-borne parasites, such as tapeworms and flukes that can be caught by humans if they eat undercooked fish. However, the HPA says that there is no evidence that these can be caught from a fish pedicure as this would require ingestion of the fish or the water.
Bacterial infections
The report looked at a number of specific harmful bacteria, including those that cause salmonella and legionnaires’ disease. Generally, these were deemed to be of low risk as they would not be ingested or would need broken skin to cause infection.
However, certain bacteria were identified as posing a greater risk of infection. For example, Staphylococcus aureus might infect people’s skin if they had eczema or psoriasis. Also, a type of bacteria called Mycobacterium marinum, which is associated with fish tanks and non-chlorinated swimming pools, could cause boils if transferred into broken skin.
Fungal infections such as verrucas and athlete’s foot
Fungi are known to survive on inanimate surfaces for prolonged periods and could, therefore, be passed on by infected clients walking around barefoot. However, the HPA points out that this route of transmission is not unique to fish spas.

So are fish pedicures safe?

The Health Protection Agency says that “on the basis of the evidence identified and the consensus view of experts, the risk of infection as a result of a fish pedicure is likely to be very low”. The agency does outline some groups who are not recommended to have fish pedicures due to increased risk of infection, such as people with diabetes or compromised immune systems.
The HPA also specifically addresses the possibility of transmitting blood-borne viruses such as HIV and hepatitis. The agency says that, in theory, transmission could occur if infected blood from one person got into an open wound on another person using the same tank, although, once again, the risk is “extremely low”. In part, the risk would be minimised due to factors such as the diluting action of the water and the fact that infected blood would be unlikely to stay on the fishes’ mouths.
However, the agency does say that the risk of infections cannot be completely excluded and, in order to reduce this risk even further, they have drawn up a list of recommendations for fish spas.

What recommendations does the HPA make?

The HPA has made extensive recommendations on how fish spas can further reduce the risk of infections. Below are some of the major ones.
Groups not recommended to have a fish pedicure
The agency also says fish pedicures are not recommended for people that may increase the risk of infection or pose an infection risk to other clients. This includes people who:

• have had their legs waxed or shaved in the previous 24 hours (they may have tiny cuts that increase infection risk)
• have any open cuts, wounds, abrasions or broken skin on the feet or lower legs
• have an infection on the feet (including athlete’s foot or a verruca)
• have psoriasis, eczema or dermatitis affecting the feet or lower legs
• are diabetic (which leads to increased risk of infection)
• have a blood-borne virus such as hepatitis B, hepatitis C or HIV
• have an immune deficiency due to illness or medication
• have bleeding disorders or take anticoagulant medication (for example, heparin or warfarin)

Safety procedures for fish spas
The HPA recommends that:

• Clients should be provided with medical information on any potential risk, including specific guidance on conditions that raise infection risk.
• Clients should have their feet examined both before and after treatment to make sure they are free from cuts and infections. Staff should log that these checks have been performed.
• Feet should be thoroughly washed and rinsed before a pedicure to minimise the number of micro-organisms transferred into the tank.
• If there is evidence that bleeding has occurred during a session the tank should be drained and cleaned thoroughly. The HPA has drawn up thorough guidelines on how to disinfect tanks in a fish-friendly way. After 48 hours in a holding tank the fish can be reused.
• Clients should be told to seek advice from their GP if they experience any adverse effects.

Links to the headlines

Fish foot spa virus bombshell. The Sun, October 18 2011
Health risk from fish pedicures. The Daily Telegraph, October 18 2011

Links to the science

Fish pedicures unlikely to cause infection. HPA 2011

EU rules on health staff 'put patients at risk'

The European Commission is already reviewing the regulations

Patients are being put at "unacceptable risk" because of EU rules governing the movement of health workers, peers say.

A House of Lords committee said the current balance between free movement of labour and safety had been skewed.
It said regulatory bodies should be able to test the language skills of all doctors, nurses, midwives, dentists and pharmacists wanting to work in the UK.
They also called for better sharing of data about the disciplinary history of staff seeking to work abroad.
The ability of health professionals - and in particular doctors - to work across the European Economic Area (EEA) has been a controversial issue in the UK in recent years.
It hit the headlines after the case of Daniel Ubani, a German locum doctor, who gave 70-year-old David Gray a fatal painkiller overdose on his first and only shift in Britain in February 2008.
Investigations found Dr Ubani had been rejected for work in Leeds because of his poor English skills, but had been allowed on an approved list by another trust.
A UK coroner recorded a verdict of unlawful killing and accused Dr Ubani of gross negligence.
Frustration
The GP was given a suspended sentence in Germany for death by negligence but has still been able to work there.
Since the case, ministers and the General Medical Council, which regulates doctors in the UK, have expressed frustration at the current situation.
The European Commission has already announced a review of the rules with firm proposals expected by the end of the year.
It is likely they will recommend a tightening of the rules, although it could take another year for the changes to be made.

“Start Quote

The committee is right - the safety of patients should always come first. Like us, they believe that current EU rules are putting patients at risk and urgent changes are needed”

End Quote Niall Dickson General Medical Council

In the meantime ministers in England have placed a duty on local trusts to vet the language skills of doctors - they have had the power to do this but it was inconsistently carried out - as well as giving the GMC powers to investigate language competency where concerns are raised.

But the conclusions reached by the House of Lords social policies and consumer protection committee call for a much more radical overhaul.
The peers have suggested that an alert system be set up to ensure that information about disciplinary procedures are shared between regulators from different countries.
They also want regulators to be given the power to vet language skills - as they have for doctors from outside the EEA - while the qualifications and skills recognised as being appropriate need to be updated to ensure staff are trained to the appropriate standards.
Committee chairwoman Baroness Young said: "It is absolutely unacceptable that current EU rules put patients at risk. The EU is failing our patients.
"We recognise that mobility can bring significant benefits, but we have to make sure that this is not at the expense of patients' health, care and confidence."
The report has been warmly welcomed by regulators, ministers and campaigners in the UK.
Niall Dickson, chief executive of the General Medical Council, said: 'The committee is right - the safety of patients should always come first. Like us, they believe that current EU rules are putting patients at risk and urgent changes are needed."
And Peter Walsh, chief executive of Action Against Medical Accidents, described the current arrangements as "crazy".
"Patient safety must be put before political correctness."
Health Secretary Andrew Lansley added: "It's completely unacceptable for doctors to work in the NHS if they can't speak English properly."

Viking boat burial discovery 'a first' \

Ardnamurch Viking boat burial discovery 'a first'an

The sword, axe head and a bronze ring pin recovered from the burial site

• Viking coins declared as treasure
• Skye Viking shipyard from the sky
• Aerial surveys of Viking shipyard

The UK mainland's first fully intact Viking boat burial site has been uncovered in the north-west Highlands, archaeologists have said.

The site, at Ardnamurchan, is thought to be more than 1,000 years old.
Artefacts buried alongside the Viking in his boat suggest he was a high-ranking warrior.
Archaeologist Dr Hannah Cobb said the "artefacts and preservation make this one of the most important Norse graves ever excavated in Britain".
Dr Cobb, from the University of Manchester, a co-director of the project, said: "This is a very exciting find."
She has been excavating artefacts in Ardnamurchan for six years.
The universities of Manchester, Leicester, Newcastle and Glasgow worked on, identified, or funded the excavation.

Dr Oliver Harris from the University of Leicester says the burial artefacts belonged to a high-status individual

Archaeology Scotland and East Lothian-based CFA Archaeology have also been involved in the project which led to the find.
The term "fully-intact", used to describe the find, means the remains of the body along with objects buried with it and evidence of the boat used were found and recovered.
The Ardnamurchan Viking was found buried with an axe, a sword with a decorated hilt, a spear, a shield boss and a bronze ring pin.
About 200 rivets - the remains of the boat he was laid in - were also found.
Previously, boat burials in such a condition have been excavated at sites on Orkney.
Until now mainland excavations were only partially successful and had been carried out before more careful and accurate methods were introduced.
Other finds in the 5m-long (16ft) grave in Ardnamurchan included a knife, what could be the tip of a bronze drinking horn, a whetstone from Norway, a ring pin from Ireland and Viking pottery.
'The icing'
Dozens of pieces of iron yet to be identified were also found at the site.
The finds were made as part of the Ardnamurchan Transition Project (ATP) which has been examining social change in the area from the first farmers 6,000 years ago to the Highland Clearances of the 18th and 19th centuries.

Helena Gray of East Lothian-based CFA Archaeology with axe head

Viking specialist Dr Colleen Batey, from the University of Glasgow, has said the boat was likely to be from the 10th Century AD.
Dr Oliver Harris, project co-director from the University of Leicester's School of Archaeology and Ancient History, reinforced the importance of the burial site.
He said: "In previous seasons our work has examined evidence of changing beliefs and life styles in the area through a study of burial practices in the Neolithic and Bronze age periods 6,000-4,500 years ago and 4,500 to 2,800 years ago respectively.
"It has also yielded evidence for what will be one of the best-dated Neolithic chambered cairns in Scotland when all of our post-excavation work is complete.
"But the find we reveal today has got to be the icing on the cake."

“Trendy fish pedicures could spread HIV and hepatitis

“Trendy fish pedicures could spread HIV and hepatitis C,” The Sun has today reported. Its front-page story said that officials have raised an “alert” over the treatment, popular in beauty spas, where tiny fish are used to nibble away areas of hard foot skin.

While The Sun has been carping on about warnings and alerts, the newspaper seems to have overestimated the scale of the risk, which health experts have described as being “extremely low”. Rather than being an alert, the news is based on a report by the Health Protection Agency that has set out good practice for so-called ‘fish spas’ that offer the service.

While the report did acknowledge that the risk of infections could not be completely ruled out, it is important to view this in context and not be reeled in by fishy headlines.

What exactly is a fish pedicure?

A fish pedicure is a beauty treatment that uses dozens of tiny fish to nibble away dead and hardened skin from the feet. During a session a person immerses their feet in a tank of warm water and lets the minute, toothless Garra rufa fish nibble away for around 15 to 30 minutes. The fish are said only to eat dead skin, although there are some anecdotal reports that they can break the skin if they nibble too deep.

Fish pedicures have long been used as beauty treatments in Turkey and the Far East, but have only recently been introduced to this country. In the few years since the first UK ‘fish spa’ opened the treatment’s popularity has rocketed due to celebrity endorsements and high-profile press coverage. The HPA says that, as of spring 2011, it is aware of 279 in operation (although there are likely to be many more).

A small number of spas may also be using other species of fish to perform pedicures, such as Chin chin fish. However, the HPA says that these should not be used as they develop teeth when they get older, and may therefore present a greater risk to public health.

What did the report examine?

The report examined a number of issues relating to fish pedicures, including:

• potential ways infections might occur
• the risk of catching blood-borne viruses, including HIV and hepatitis
• the risk of bacterial infections
• the risk of catching parasites, such as fluke worms
• the risk of transmitting conditions, such as athlete’s foot and verrucas
• procedures that might reduce any health risks

The report is based on consultations with experts and professional bodies within the fields of public health, aquaculture, health and safety, and animal welfare.

What did the report find?

The report considered three main ways that a person might catch an infection:

• from a fish or a fish tank
• from tank water
• from another person via surfaces, such as floors

Within these areas they considered the different types of infections that might occur.

Blood-borne viruses

Viruses such as HIV and hepatitis are carried in the blood and, in theory, could be transmitted through tank water if someone with a cut or abrasion were to use a tank containing traces of blood from an infected person with cuts.

However, there is only anecdotal evidence that Garra rufa fish can draw blood, and the HPA says that any blood-borne viruses they come into contact with are unlikely to stay on the surface of their mouths and lead to infection. Any blood entering the tank is likely to be diluted by the volume of water used.

While transmission through this method cannot be completely ruled out, the HPA says the risk of catching a blood-borne virus in this way is extremely low. Further to this, the HPA is recommending that the fish spas check clients for cuts and abrasions both before and after their session.

Parasites

Fish-borne parasites, such as tapeworms and flukes that can be caught by humans if they eat undercooked fish. However, the HPA says that there is no evidence that these can be caught from a fish pedicure as this would require ingestion of the fish or the water.

Bacterial infections

The report looked at a number of specific harmful bacteria, including those that cause salmonella and legionnaires’ disease. Generally, these were deemed to be of low risk as they would not be ingested or would need broken skin to cause infection.

However, certain bacteria were identified as posing a greater risk of infection. For example, Staphylococcus aureus might infect people’s skin if they had eczema or psoriasis. Also, a type of bacteria called Mycobacterium marinum, which is associated with fish tanks and non-chlorinated swimming pools, could cause boils if transferred into broken skin.

Fungal infections such as verrucas and athlete’s foot

Fungi are known to survive on inanimate surfaces for prolonged periods and could, therefore, be passed on by infected clients walking around barefoot. However, the HPA points out that this route of transmission is not unique to fish spas.

So are fish pedicures safe?

The Health Protection Agency says that “on the basis of the evidence identified and the consensus view of experts, the risk of infection as a result of a fish pedicure is likely to be very low”. The agency does outline some groups who are not recommended to have fish pedicures due to increased risk of infection, such as people with diabetes or compromised immune systems.

The HPA also specifically addresses the possibility of transmitting blood-borne viruses such as HIV and hepatitis. The agency says that, in theory, transmission could occur if infected blood from one person got into an open wound on another person using the same tank, although, once again, the risk is “extremely low”. In part, the risk would be minimised due to factors such as the diluting action of the water and the fact that infected blood would be unlikely to stay on the fishes’ mouths.

However, the agency does say that the risk of infections cannot be completely excluded and, in order to reduce this risk even further, they have drawn up a list of recommendations for fish spas.

What recommendations does the HPA make?

The HPA has made extensive recommendations on how fish spas can further reduce the risk of infections. Below are some of the major ones.

Groups not recommended to have a fish pedicure

The agency also says fish pedicures are not recommended for people that may increase the risk of infection or pose an infection risk to other clients. This includes people who:

• have had their legs waxed or shaved in the previous 24 hours (they may have tiny cuts that increase infection risk)
• have any open cuts, wounds, abrasions or broken skin on the feet or lower legs
• have an infection on the feet (including athlete’s foot or a verruca)
• have psoriasis, eczema or dermatitis affecting the feet or lower legs
• are diabetic (which leads to increased risk of infection)
• have a blood-borne virus such as hepatitis B, hepatitis C or HIV
• have an immune deficiency due to illness or medication
• have bleeding disorders or take anticoagulant medication (for example, heparin or warfarin)

Safety procedures for fish spas

The HPA recommends that:

• Clients should be provided with medical information on any potential risk, including specific guidance on conditions that raise infection risk.
• Clients should have their feet examined both before and after treatment to make sure they are free from cuts and infections. Staff should log that these checks have been performed.
• Feet should be thoroughly washed and rinsed before a pedicure to minimise the number of micro-organisms transferred into the tank.
• If there is evidence that bleeding has occurred during a session the tank should be drained and cleaned thoroughly. The HPA has drawn up thorough guidelines on how to disinfect tanks in a fish-friendly way. After 48 hours in a holding tank the fish can be reused.
• Clients should be told to seek advice from their GP if they experience any adverse effects.

Links to the headlines

Fish foot spa virus bombshell. The Sun, October 18 2011

Health risk from fish pedicures. The Daily Telegraph, October 18 2011

Links to the science

Fish pedicures unlikely to cause infection. HPA 2011

Climate change 'grave threat' to security and health

Food security was interwoven with the climate issue, speakers told the conference

Climate change poses "an immediate, growing and grave threat" to health and security around the world, according to an expert conference in London.

Officers in the UK military warned that the price of goods such as fuel is likely to rise as conflict provoked by climate change increases.
A statement from the meeting adds that humanitarian disasters will put more and more strain on military resources.
It asks governments to adopt ambitious targets for curbing greenhouse gases.
The annual UN climate conference opens in about six weeks' time, and the doctors, academics and military experts represented at the meeting (held in the British Medical Association's (BMA) headquarters) argue that developed and developing countries alike need to raise their game.
Scientific studies suggest that the most severe climate impacts will fall on the relatively poor countries of the tropics.
UK military experts pointed out that much of the world's trade moves through such regions, with North America, Western Europe and China among the societies heavily dependent on oil and other imports.
Rear Admiral Neil Morisetti, climate and energy security envoy for the UK Ministry of Defence (MoD), said that conflict in such areas could make it more difficult and expensive to obtain goods on which countries such as Britain rely.
"If there are risks to the trade routes and other areas, then it's food, it's energy," he told BBC News.
"The price of energy will go up - for us, it's [the price of] petrol at the pumps - and goods made in southeast Asia, a lot of which we import."
Coffee climate
A number of recent studies have suggested that climate impacts will make conflict more likely, by increasing competition for scare but essential resources such as water and food.
The International Institute for Strategic Studies, for example, recently warned that climate change "will increase the risks of resource shortages, mass migration and civil conflict", while the MoD's view is that it will shift "the tipping point at which conflict occurs".

Armed forces are "the gas-guzzlers of the world"

Alejandro Litovsky, founder of the Earth Security Initiative, said that even without the increasing effect of conflict, prices of essential goods were bound to rise.
"From the year 2000 onwards, we have been seeing commodity prices climb, and this is not likely to stop," he said.
"It is primarily driven by resource scarcity, and the trends suggest that depletion of these natural resources is unlikely to be reversed in the near future without drastic interventions."
He also said that degradation of natural resources such as forests and freshwater was removing much of the resilience that societies formerly enjoyed.
Last week, multinational coffee house Starbucks warned that climate change threatened the world's coffee supplies in 20-30 years' time.
Compromised by carbon
The military officers at the meeting also emphasised the interest that armed forces have in reducing their own carbon footprint.
In Afghanistan, for example, fuel has to be delivered by road from Pakistan.
By the time it reaches its destination, it can cost 10 times the pump price. And the convoys are regularly targeted by opposing forces.
Several officers admitted that armed forces were "the gas-guzzlers of the world" - and while that was sometimes necessary in operations, reducing fossil fuel use and adopting renewables wherever possible made sense from economic and tactical points of view.
Rear Admiral Morisetti recalled that when commanding an aircraft carrier, it took a gallon of oil to move just 12 inches (30cm), while as many as 20 tonnes per hour were burned during a period of intensive take-off and landing.
"You can do that [with oil prices at] $30 a barrel, but not at $100 or $200," he said.
Health gains
On the health side, doctors warned of a raft of impacts, particularly in developing countries.
Hunger and malnutrition were likely to increase, and some infectious diseases were likely to spread, they said.
Poorer societies could expect to see an unholy symbiosis between the two, with under-nourished people more prone to succumb to infections.
Tackling carbon emissions, by contrast, would bring a range of health benefits, they argue in their statement.
"Changes in power generation improve air quality.
"Modest life style changes - such as increasing physical activity through walking and cycling - will cut rates of heart disease and stroke, obesity, diabetes, breast cancer, dementia and depressive illness.
"Climate change mitigation policies would thus significantly cut rates of preventable death and disability for hundreds of millions of people around the world."
No cause for optimism
As the UN summit in South Africa approaches, the statement here calls on the EU to increase its ambition and pledge to reduce emissions by 30% from 1990 levels by 2020, rather than the current target of 20%.
Currently, there does not appear to be political consensus for such a move within EU governments, however.
Additional recommendations are that developing country governments should analyse climate threats to their health and security, and that all governments should stop construction of new coal-fired power stations without carbon capture and storage (CCS) - which, as commercial CCS systems do not exist, would as things stand amount to a complete ban.
Without urgent action, carbon emissions could rise to levels that should cause major alarm, said Chris Rapley, professor of climate science at University College London.
Already, he noted, the atmospheric concentration of carbon dioxide has risen to about 380 parts per million [ppm] - whereas in the millions of years before the pre-industrial era, it fluctuated between about 180ppm during Ice Ages and about 280ppm in the warm interglacial periods.
"If we don't do something, then at the rate we're going, carbon emissions will continue to accelerate, and the atmospheric concentration is not going to be 450ppm or 650ppm by the end of the century, but 1,000ppm," he said.
"That is 10 times the difference between an Ice Age and an interglacial; and you have to be a pretty huge optimist to think that won't bring major changes."

a government body ‘routinely approving even obviously damaging projects’ that affect India’s forests.

Monday, 17 October 2011

a government body ‘routinely approving even obviously damaging projects’ that affect India’s forests.

Dongria Kondh protest against Vedanta Resources, Niyamgiri, India © Survival

Three highly respected experts have criticised

In a letter to India’s Ministry of Environment and Forests, the three said the departments responsible had ‘abdicated their role of due diligence’.

Ullas Karanth, a tiger expert, Amita Baviskar, who has written extensively on India’s tribal peoples, and Mahesh Rangaragan, a highly respected environmental expert, are all are non-official members of the committee they have criticised.

One of the main concerns raised in the letter was the use of poor, and often biased information to make extremely important decisions.

The committee is responsible for recommending whether mega projects such as the Niyamgiri mine should be allowed on forest land.

In relation to the Orissa project, the experts described how flippantly decisions were made: ‘A retired senior official claimed there was an animal with stripes that could either have been a tiger or a hyena (and this on the basis of discussion at roadside tea shops)!’

The group are appealing for more thorough and independent research to be carried out before such decisions are made in the future.

The accusations come at a critical time for India’s Dongria Kondh tribe, as the notorious Niyamgiri mine is back under discussion in the Supreme Court.

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NHS ombudsman in England criticises complaint handling

The NHS needs to get better at handling complaints

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Related Stories

• NHS complaints system 'failing'
• Record increase in NHS complaints

The NHS in England is still failing to deal with complaints properly, with poor communication a major problem, the Health Service Ombudsman says.

The watchdog, which looks at cases that cannot be resolved at a local level, said too many minor disputes were being allowed to escalate.

Some GPs were removing patients who had complained from their lists, it said.

It handled more than 15,000 complaints in 2010-11 but two-thirds went back to the local area for adjudication.

On doctors striking off patients, the ombudsman said there were a small but increasing number of cases where this was happening without warning - something which was worrying bearing in mind GPs are to take charge of the NHS budget.

'Dissatisfied patients'

Ombudsman Ann Abraham, who has the final say on complaints in England, said: "The NHS is still not dealing adequately with the most straightforward matters. Minor disputes over unanswered telephones or mix-ups over appointments can end up with the ombudsman because of knee-jerk responses by NHS staff and poor complaint handling.

"While these matters may seem insignificant alongside complex clinical judgements and treatment, they contribute to a patient's overall experience of NHS care.

"What is more, the escalation of such small, everyday incidents represents a hidden cost, adding to the burden on clinical practitioners and taking up time for health service managers, while causing added difficulty for people struggling with illness or caring responsibilities."

Continue reading the main story

Left waiting for two years

Mr C made a complaint about the care his sister received after she died while receiving palliative chemotherapy.

His complaint was rejected by the trust so he then appealed to the ombudsman. His appeal was not upheld, but the way the trust handled it was criticised.

Records were not reviewed properly, statements were made that were not supported by information, documents left unsigned and undated and the trust used medical jargon when dealing with the individual, the ombudsman ruled.

Mr C said the process, which took two years to complete, had prolonged his suffering.

The trust apologised and now uses the case as an example of how not to handle complaints during training for staff.

Of the 15,186 complaints dealt with, 9,547 were referred back to the local health body because they had not completed the complaints procedure.

Only 349 were investigated with 79% (276) upheld with the others either withdrawn, falling outside the remit of the ombudsman or judged not to be justified.

Where individuals were unhappy with how their complaint had been dealt with, over a third cited either poor explanation or a lack of acknowledgement of a mistake.

In one of the most extreme cases Parliament was alerted after a dentist from Staffordshire refused to apologise to one of their patients.

Jo Webber, of the NHS Confederation, which represents trusts, said it was "absolutely essential" that the health service got better at dealing with complaints.

"We all know that things can go wrong in health care but where that happens people are entitled to be dealt with in a straightforward and respectful fashion."

But patient groups said the figures were concerning for other reasons. Both Patient Concern and Action Against Medical Accidents highlighted the fact that the ombudsman only took on a small number of complaints for investigation.

Joyce Robins, co-director of Patient Concern, said: "The ombudsman investigates a pathetic 2% of complaints reaching her office.

"There is no other right of appeal and the vast majority of dissatisfied patients are left at the mercy of trusts who are only concerned with watching their backs."

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• NHS complaints system 'failing' 28 JUNE 2011, HEALTH
• Record increase in NHS complaints 25 AUGUST 2010, HEALTH

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• Parliamentary and Health Service Ombudsman

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Monday, 17 October 2011

Better hospital IT 'would save thousands of lives'

Better hospital IT 'would save thousands of lives'

Medication errors were halved by using the IT system, the report authors say

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• New warning for Stafford hospital
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Better use of information technology in England's hospitals could help prevent 16,000 deaths a year, a report says.

University Hospitals Birmingham has recommended its system to the team investigating above-average death rates from 2005 to 2008 at Stafford Hospital.

The trust says it saw a 17% fall in deaths among emergency patients over 12 months, which would equate to 16,000 deaths prevented across England.

Systems include a computer reminding staff to give patients their drugs.

The trust says IT surveillance on its wards is backed up by a policy of holding staff to account for errors.

The report shows how the trust has harnessed IT to bear down on errors, with the initial focus on preventing missed medications. Evidence suggests that hospitals may miss one dose in every five.

Staff at the trust are issued with computer-generated reminders, and the system also issues warnings to prevent prescriptions which could harm the patient.

The number of medication errors at the trust has halved, which has coincided with a sharp fall in deaths for patients admitted as an emergency, the report says.

Missed medications are just one of many clinical activities that are monitored on University Hospitals Birmingham's computer database, and presented to staff on the wards on a dashboard display.

It also includes falls, checks for blood-clots and infection control.

The system also generates alarms when staff key-in clinical information that could give cause for concern, such as changes to a patient's temperature, heart rate, or blood pressure. This triggers an alert in the critical care Unit, prompting an outreach team to be dispatched to wherever they are needed in the hospital.

Where mistakes arise, the real-time feedback to senior executives enables them to call staff to account, with regular reviews to assess and explain performance.

'Culture change'

The trust's medical director, Dr Dave Rosser, said nurses in modern healthcare have trained and worked in an environment where one in five drugs is not given and that this has become the norm.

"It has become over the decades culturally acceptable for drugs not to be given to patients, and what we've been trying to do here is turn round that culture and say every single dose is important."

Dr Rosser was asked to present a report to the public inquiry into the Mid Staffordshire NHS scandal. The paper shows that mortality rates for patients admitted as an emergency fell by nearly 17% over a 12-month period, but remained static in the rest of England. He said that if his trust's approach was adopted across the NHS, this would equate to 16,000 deaths avoided.

The matron in the critical care unit at the Birmingham trust's Queen Elizabeth hospital, Helen Gyves, said nurses recognised the value of tight clinical scrutiny.

"All of the ITU nurses work in a hi-tech environment so they are used to the impact of IT. So if you asked us why we hadn't done something or if you can give us evidence to prove that by challenging us things will improve for the patient, then we wouldn't mind."

The matron in the hospital's clinical decision unit, Liz Miller, said increased accountability had improved the culture of care.

"A good nurse ensures that all of the care is given to the patient. Not just the medication, not just the fluid, but also the personal hygiene, those nursing touches, the communication with the patients. How well she gives her medication and how on time she gives her medication is a good barometer of the all-round care that she gives."

The system at University Hospitals Birmingham is one of several commercially available to the NHS. The chief executive of the Patients Association, Katherine Murphy, welcomed the work at the trust.

"This system has the potential to really make a big difference to patient safety across the board. By highlighting ongoing problems and trends in patient care, ward and trust leaders can put changes in place to prevent other patients from suffering in the same way, learning from their mistakes rather than trying to bury them under bureaucracy."

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• New warning for Stafford hospital 10 OCTOBER 2011, STOKE & STAFFORDSHIRE
• NHS missing patient safety alerts 12 AUGUST 2010, HEALTH
• Grim toll of missed safety alerts 16 FEBRUARY 2010, HEALTH

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• University Hospitals Birmingham

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