Number of strokes in UK predicted to rise by 44% in next 20 years

The number of strokes in the UK is expected to increase by almost half over the next 20 years owing to the ageing population, according to a study.

Over the same period, the number of stroke survivors is predicted to rise by a third, raising questions about how the already stretched NHS and social care services will cope.

King’s College London analysed data from 35 European countries, finding that the number of strokes across the continent is likely to rise by a third (34%) by 2035. But the increase in the UK is expected to be more pronounced at 44%, owing to the rate at which the country’s population is ageing relative to many other European countries.

By 2035 the number of UK stroke cases is expected to increase by 44% to about 62,000 a year

Alexis Wieroniey, deputy director of policy and influencing at the Stroke Association, said: “The predicted rise in the burden of stroke is largely due to our ageing population, as the risk of having a stroke increases as you get older. It is a worrying forecast, but it is not inevitable.

“Most strokes are preventable and everyone can take steps to lower their risk of stroke as they get older. Obesity can increase your risk of stroke by at least 64%. However, simple lifestyle changes like eating healthier meals, taking regular exercise and stopping smoking, along with checking your blood pressure regularly, can greatly reduce your risk.”

According to the Stroke Association, an estimated 1.2 million people are currently living with the effects of stroke. It says there are more than 100,000 strokes each year.

Spending on stroke patients

The King’s College London analysis is published on the same day as the British Medical Association warns that the UK is facing a health time bomb owing to a failure in addressing the burden placed on the NHS by obesity, smoking and alcohol consumption.

The BMA points to figures showing that nearly one in six adults still smoke, 7.8 million adults binge drink and obesity rates remain stubbornly high. It says there has been a failure to publish a new tobacco control plan and a lack of recognition of the need for a new alcohol strategy. It also describes the childhood obesity strategy as “watered-down”.

In its manifesto, A Vote for Health, the BMA says whichever party wins the general election should reverse the £400m of public health cuts taking place between 2015-16 and 2020-21.

Dr Mark Porter, chair of the BMA council, said: “In England, successive governments have failed to deliver a long-term plan to improve public health, and too often evidence-based public health measures have been kicked into the long grass. We need tighter regulation of the food and soft drinks industry, a minimum unit price on alcohol and support for people to quit smoking.”

The Stroke Association says a plan to tackle strokes is also essential given the projected rise in the number of cases. The current stroke strategy for England is scheduled to end this year, leaving it as the only UK nation without such a plan.

A Conservative party spokeswoman said: “We are committed to improving the health of the nation. Smoking rates are now the lowest in our history, with cancer survival the highest, and we’ve put in place a childhood obesity plan Public Health England calls the most ambitious in the world.

“But the truth is that this all depends on a strong economy – we spent £3.4bn on public health programmes last year – which Jeremy Corbyn would risk with his nonsensical economic ideas.”

Number of strokes in UK predicted to rise by 44% in next 20 years

Number of NHS managers still growing as GP posts fall again

The number of NHS managers has grown by almost 18% in the four years since the government introduced a “bureaucracy-busting” shakeup of the health service, according to the latest official data.

The rise of about 4,650 in total management posts since April 2013, when the controversial Health and Social Care Act came into force, contrasts with an alarming fall in the number of GPs over recent months at a time of unprecedented demand for health care. The figures have drawn criticism from the British Medical Association (BMA), who say ministers are failing in their central objective of shifting more resources and manpower from back-office posts to the front line.

NHS Digital figures show management posts have risen from 26,051 in April 2013 – the month when the highly controversial act pioneered by then health secretary Andrew Lansley came into force – to 30,724 at the end of last year, the latest date for which data has been released. This is a serious embarrassment to the government, which insisted when pushing through the legislation in the last parliament – in the teeth of huge opposition from the medical profession – that a key benefit would be a freeing of resources to redirect effort to the front line.

The BMA said that it would be distressing for patients to learn that management posts were rising as GP numbers continued to fall. The latest data shows 92 GP practices closing in 2016 as GP numbers fell by 400 between October and December. Dr Richard Vautrey, deputy chair of the BMA’s GP committee, said: “Patients will be bemused that when their care is being undermined by GP and nurse staff shortages, the number of administrative posts has risen again. With the NHS at breaking point, we need ministers to get their priorities right. They need to follow through on their election pledges and invest in recruiting more GPs so that we can offer enough appointments to the public.”

Under David Cameron’s premiership, the coalition government said its health reforms, which handed control over commissioning services to GPs, would “cut the number of health bodies to help meet the government’s commitment to cut NHS administration costs by a third, including by abolishing primary care trusts and strategic health authorities”.

The process now appears to have gone into reverse. Between 2015 and 2016 the number of managers and senior managers in the NHS in England increased by about 3.5% in hospitals, trusts and clinical commissioning groups.

At the 2010 election the Tories put a promise to cut NHS bureaucracy at the heart of their pitch to voters. Before unveiling the Health and Social Care Act, they began cutting management posts, which were reduced by 12,000 between 2010 and early 2013. But as the requirements of the changes became clear, many who had been handed redundancy payoffs were then hastily re-employed only months later, some on six-figure salaries, to help run the new-look service.

The current health secretary Jeremy Hunt announced plans in 2014 to “train and retain” 5,000 more GPs by 2020, a pledge since watered down to also include doctors in training. According to the latest NHS England figures, however, 92 practices closed in 2016, up 114% on GP surgery closures in 2014. While 34 merged with other practices, the remainder shut completely.

Last week a survey carried out by the University of Exeter found that two out of every five GPs in the south-west of England were planning to leave the profession, with many citing workload and low morale as reasons.

There are also fears that an exodus of doctors and nurses from other EU countries will accelerate as the UK prepares to leave the EU. A total of 2,348 doctors from the 27 other EU states left NHS England between July and September 2016 compared with 1,281 in the same period in 2015 – a rise of 83%.

An NHS England spokesperson said: “The OECD says that on a like-for-like basis we spend only 2p in the pound on NHS administration, compared to 5p in Germany and 6p in France, and we have one of the most efficient health services in the world. But over the next three years we’re going to cut at least another quarter of a billion pounds from administrative costs to reinvest in frontline patient care.”

Number of NHS managers still growing as GP posts fall again

A&E redirecting increasing number of ambulances to other hospitals

A record number of ambulances were turned away from busy A&Es this winter and sent to other hospitals, preventing paramedics from responding to urgent calls quickly enough, according to a study.

The Nuffield Trust, a health thinktank, looked at NHS England data and found that nearly twice as many patients arriving in ambulances were turned away from hospitals and sent elsewhere this year compared with the same period over the last three years.

Ambulances were redirected 478 times over the three-month period from December to February, compared with an average of 249 times in 2013-14, 2014-15 and 2015-16. The NHS refers to such incidents caused by a lack of physical or staff capacity as “diverts”and says they should be a last resort.

The thinktank said this had a direct effect on paramedics’ ability to respond to emergencies – with none of the three main response targets having been hit since May 2015. Prof John Appleby, Nuffield Trust chief economist and lead author of the report, said: “There’s rightly been a lot of focus recently on the delays ambulance crews face in being able to hand over their most seriously ill patients at A&E.

“But what our research today has uncovered is the huge increase in the number of times this winter [that] ambulance trusts have been told they must take patients to another hospital altogether, because an A&E unit simply doesn’t have the capacity to accept any more patients.”

Of the 233,472 most serious category A calls received in January this year, at least 95% should have been responded to in 19 minutes. But 29,000 calls were not picked up within this timeframe, meaning 88% of responses met the target.

Richard Webber, national spokesperson for the College of Paramedics and a senior paramedic in the NHS, said: “While we are sympathetic to hospitals that are forced to implement diverts so that they don’t reach dangerous levels of overcrowding, in non-urban areas in particular the extra time taken to reach more distant A&E departments is significant.”

The report also found that paramedics were under increased pressure, with demand for the service rising at a faster rate than emergency admissions to hospital and A&E attendances. The Nuffield Trust said that morale in the sector was also poorer than other parts of the health service.

The figures come as the government faces calls to address growing demand on A&Es. In January, patients in England experienced the worst month of delays in emergency departments since a four-hour target was introduced 13 years ago.

Jonathan Ashworth, the shadow health secretary, said: “Theresa May has overseen a shocking and unacceptable decline in standards for the NHS this winter. Our ambulance services are under increasing pressure and we know that ambulance staff across England are really feeling the strain. They deserve much more support from the government.

“The truth is that years of under-investment by the Conservatives have left hospitals unable to cope with rising demand, and now shocking numbers of ambulances are being diverted because A&Es are stretched to the limits. The government urgently needs to set out what action they’re going to take to make sure patients and their families never have to suffer a winter like this again.”

An NHS England spokesman said: “Currently too many ambulances are dispatched to simply hit targets rather than attend to those patients most in need. This is why we’re carefully testing a change to the way in which the services can respond and will make our recommendations known in the coming weeks.”

A&E redirecting increasing number of ambulances to other hospitals

Record number of GP closures force 265,000 to find new doctors

A record number of GP practices closed last year, forcing thousands of patients to find a new surgery, in spite of government attempts to stop local doctors shutting their doors.

NHS England data showed nearly a hundred practices closed in 2016, a 114% increase in GP closures compared with figures from 2014. Of the 92 practices that shut, 58 did so completely, while 34 merged with other local surgeries in order to pool resources.

The drop in GP numbers meant 265,000 patients – an increase of 150% from 2014 – had to change their practice last year, often travelling further for care. Brighton was particularly badly affected with 9,000 patients displaced when four practices closed. There have been a total of seven closures in the city over the past two years.

The new data, obtained by the GP website Pulse, has renewed fears that family doctors are not coping with increased demand and need an urgent cash injection to survive. Senior doctors also expressed concern that government funding was not being targeted correctly.

patients displaced

gp practices close

It comes despite the NHS announcing its GP forward view plan last year, promising to invest an annual £2.4bn into services by 2020. The government also announced £500m investment as a rescue package, which included £16m to support vulnerable practices.

Dr Chaand Nagpaul, chairman of the British Medical Association’s GP committee, told Pulse: “We know the money, targeted in the right way, for the most severely affected practices, can make a difference.

“The tragedy is clinical commissioning groups have not delivered their part in making the resources available. Many practices that should have received support have had none to date. That’s been a failing of local delivery.”

Prof Helen Stokes-Lampard, chair of the Royal College of GPs, said: “Too many practices are being forced to close because GPs and their teams can no longer cope with ever-growing patient demand without the necessary funding and workforce to deal with it. This has serious consequences for patient safety and the wellbeing of hard-working family doctors and their practice teams.”

The findings are likely to put more pressure on the government to address a growing NHS crisis, with hospitals and family doctors under increasing pressure.

Jonathan Ashworth MP, the shadow health secretary, said: “These are startling revelations and really bring home the extent to which Theresa May’s NHS funding squeeze is impacting on people every day in communities across the country.”

He added: “Given the crisis in hospitals we’ve seen we need to be taking the pressure off hospitals. That means doing much more to protect GP services. With Labour, general practice will be at the heart of making the English NHS more focused on care closer to home.”

Norman Lamb, the Liberal Democrat health spokesman, said: “There is a pressing need for a national, cross-party discussion about how we can afford a modern, efficient, and effective health and care system. I once again urge the prime minister to begin such a process. We must face up to the scale of this challenge, and to the possibility that we might have to pay a little more in tax to ensure that everyone gets the high-quality healthcare they should expect.”

An NHS England spokesperson said: “All NHS patients wanting to register with a GP practice are guaranteed to be able to do so and we have increased investment in general practice by £1bn in two years in order to improve services and boost GP numbers.

“These figures as presented don’t reflect the full picture as they include patients whose records automatically transfer after a merger and therefore don’t have to change practice. As part of our plans to improve general practice services and boost the workforce, many practices are choosing to merge in order to offer patients a much greater range of services.”

Record number of GP closures force 265,000 to find new doctors

Record number of EU citizens quit working in NHS last year

A record number of EU nationals left the NHS last year, renewing fears that Brexit could exacerbate a staffing crisis.

The figures, compiled by NHS Digital, prompted medical leaders to call for more reassurances to European workers about their future in the UK. A total of 17,197 staff, including nurses and doctors, left their posts in 2016, compared with 13,321 in 2015 and 11,222 for 11 months in 2014.

Even though EU staff numbers rose across the period analysed, experts fear the number of people leaving is the more significant trend.

As Britain embarks on fraught Brexit negotiations, the Royal College of Physicians (RCP) and the British Medical Association (BMA) blamed the increase in departures on the prime minister’s lack of assurances about the position of EU nationals resident in the UK. Theresa May has said such a pledge would weaken her ability to negotiate a good deal for Britain as it prepares to leave the trade bloc.

Prof Jane Dacre, the RCP president, said: “These figures confirm our fears that EU doctors are feeling unsettled and, at worst, leaving or planning to leave the UK. We need the government to provide reassurance that we will be able to keep our European colleagues, in the NHS and research, as we will not be able to replace them with homegrown doctors for many years to come.”

The BMA’s council chair, Dr Mark Porter, said: “Following the EU referendum, thousands of EEA [European Economic Area] nationals working in the NHS and wider health and social care system have been left feeling uncertain as to whether they and their families will have the right to live and work here.

“Worryingly, one in four EEA doctors working in the UK have told the BMA that they are considering leaving following the referendum, with many feeling substantially less appreciated by the government. These are people who have dedicated years of service to healthcare, staffing our hospitals, GP surgeries and leading medical research.”

Analysis by the Guardian shows 2,348 doctors from the 27 other EU states left NHS England between July and September 2016 compared with 1,281 in the same period in 2015. That is a rise of 83% year on year. The figures mirror concerns raised about the growing numbers of nurses leaving the health service and the falling number EU nationals registering as nurses in England, which dropped by 92% since the Brexit vote last June.

Number of EU doctors who left NHS England each month between February 2014 and November 2016

The NHS Digital data also shows an increase in other members of NHS staff leaving the health service. In total, 6,391 EU workers quit in the three months after the EU referendum, compared with 4,125 in the same period in 2015 – a 55% increase. The increase in the number of EU staff employed by NHS England in the same period was 15%.

A number of NHS staff told the Guardian they knew colleagues who were considering leaving. One health worker from London, who asked to be anonymous, said: “I am worried. I work in operating theatres and I walk into some of them and they are all EU staffed.

“Every theatre in London has a European citizen in it. Heaven help us if they leave. A few of my colleagues have already left – the good ones.”

A midwife from Worcester, an EU national, said: “I do know of quite a few of my colleagues who are considering leaving. Also junior doctors who aren’t eligible for permanent residency because they don’t meet the criteria. It’s a total disaster.”

Jonathan Ashworth, the Labour party health spokesman, said: “Safeguarding the future of these staff should be an absolute priority in the Brexit negotiations. Theresa May and Jeremy Hunt [the health secretary] have been totally negligent in failing to guarantee a future for these staff before article 50 was triggered.”

Concern has also been raised about a slowdown in EU nationals joining the NHS since the referendum. Figures from the Nursing and Midwifery Council show a 90% drop in the number of nurses from EU states registering to join in December.

Barry Pactor, the managing director of TTM Healthcare, an international recruitment company, said: “Since Brexit TTM Healthcare has seen a marked difference in UK perception among EU healthcare professionals.

“Overwhelmingly concern centres on a lack of clarity around their status and not knowing whether they should plan a long-term future in the UK. With such concerns it is unavoidable that EU specialists will choose alternative countries to continue their careers.”

Some were more cautious about linking the departures with the Brexit vote. Jackie Smith, registrar and chief executive of the Nursing and Midwifery Council, said: “This is the first sign of a change and it is too early to say definitively that changes in this area are due to any one reason.”‎

The Department of Health sought to downplay fears of a staffing crisis. “As the secretary of state has repeatedly made clear, overseas workers form a crucial part of our NHS and we value their contribution immensely,” a spokesperson said.

“We are continuing to invest in the frontline: there are over 34,800 more professionally qualified clinical staff, including over 11,600 more doctors and over 13,400 more nurses on our wards since May 2010. Furthermore, there are 30,000 students training to be doctors and over 52,000 training to be nurses.”

Record number of EU citizens quit working in NHS last year

Alarming number of cancer medics suffering burnout and stress

Alarming numbers of cancer doctors experience high levels of burnout, stress, sleep problems and depression, with some resorting to alcohol or sedatives to cope, research suggests.

Meta-analysis of 43 existing studies, published on Friday in Psycho-Oncology, revealed that many oncologists were struggling with the burden of dealing with suffering patients, distressed relatives and heavy workloads. It found that a third of cancer doctors were suffering from high burnout, defined as high emotional exhaustion, and a quarter had mental health problems.

The authors, from the department of organisational psychology at Birkbeck, University of London, stressed that patients were not at risk but urged doctors to be kinder to themselves.

Caroline Kamau said: “We don’t want the medical community to stigmatise distress in medical practice. A significant problem is doctors are afraid of admitting to these things. Of all the people they should be the most compassionate but they have had to soldier on and this leads to people feeling they may not be able to admit to it. Their feelings are a normal human reaction to the things doctors have to go through, particularly oncologists.”

The research considered studies from 14 countries, including the UK, US, Brazil, Australia, Japan and France, carried out between 1990 and 2014. Despite differing health systems and workloads (for example, workloads tend to be lighter in the US than in the UK), the authors said the results were consistent.

The paper highlights the fact that oncologists experience more frequent patient death than do other specialities, that they mostly work in excess of 60 hours, that they remain on call outside their formal working hours and work in a profession where understaffing is a problem.

As the studies asked different questions, the responses varied in number. Ten different studies identified stress levels among oncologists varying between 42% and 69% from a total of 1,203 responses. The burnout question was answered by more than 2,000 oncologists across the studies, and almost 5,000 responses were gathered on mental illness.

Much smaller samples found that up to 30% of oncologists drank alcohol in a problematic way – generally defined in the studies in question as drinking four or more times a week – and up to 20% were said to take “hypnotic drugs” such as sedatives, or medication to relieve anxiety or insomnia, although the authors stressed that this was outside working hours.

They say that the solution to the problems highlighted by their study should come from within the oncology community in the shape of a peer-to-peer/mentor support network.

The study’s co-author Asta Medisauskaite said: “Occupational distress reduces career satisfaction, affects patient care and increases the chances of cancer doctors switching to another area of medicine. We want to highlight that improving workload and support for oncologists could improve patient care, reduce talent loss from the field of oncology, and could ultimately impact clinical outcomes for cancer patients.”

Alarming number of cancer medics suffering burnout and stress

Record number of urgent operations cancelled in England last year

Hospitals cancelled a record number of urgent operations last year as bed shortages left them struggling to cope with the growing number of patients needing surgery, NHS figures show.

Hospitals in England cancelled a total of 4,093 urgent procedures during 2016, which equates to 341 per month. That was 8% more than the 3,777 they had to put off in 2015 and 27% up on the 3,216 such operations they cancelled during 2014.

While some cancellations occur because of the patient’s health, the large majority are due to hospitals having too few beds, especially in intensive care or high-dependency units in which patients can recover afterwards, often because a more urgent case has arrived. A few involve staff shortages or a surgeon becoming unexpectedly unavailable.

The latest figures mean that in all 17,598 patients have had their urgent operation cancelled over the past five years, often at the last minute, despite their condition requiring surgery without delay.

Opposition parties claimed the figures, published on Friday by NHS England, showed that problems in the health service were deepening and that the government was not giving it sufficient money to keep up with the rising demand for treatment.

“Theresa May’s NHS crisis continues, and the problems are worse and more widespread than in previous years. By underfunding and overstretching the NHS, the Tories have pushed health services to the brink”, said Jonathan Ashworth, Labour’s health spokesman.

Norman Lamb, his counterpart for the Liberal Democrats, added: “The government’s stubborn refusal to give the NHS emergency funding means record numbers of operations are being cancelled as hospitals face weeks on end of intolerable pressure. This will inevitably have serious repercussions for patient care and the morale of NHS staff.”

The NHS England data shows that hospitals also cancelled 38,129 non-urgent elective operations between April and October – again, the largest-ever number for those six months.

Of those patients, 2,204 did not have their rescheduled surgery within 28 days, as the NHS Constitution says they should, in another sign of the huge pressures on the service.

However, NHS England’s latest winter situation reports data showed on Frida that hospitals came under slightly less strain last week than during the “winter crisis” that unfolded in the early weeks of January.

Overall 43 acute hospital trusts were forced to divert A&E patients to another emergency department because they could not cope with the large numbers of people needing care, down from 52 the week before. Similarly, 51 trusts declared some sort of alert during the week, down from 68 a week earlier.

A further Eleven people died from flu last week, bringing the total to 53 since the start of December, and 65 needed to be treated in an intensive care or high-dependency unit.

NHS England and Public Health England said the number of flu cases hospitalswere treating was worrying and linked to the particularly cold weather affecting much of England recently.

Record number of urgent operations cancelled in England last year

MoJ launches inquiry after record number of prison suicides in 2016

The Ministry of Justice has launched an internal inquiry into the mental health backgrounds of prisoners who killed themselves, as new figures are expected to reveal that 2016 was a record high for self-inflicted deaths across prisons in England and Wales.

The justice secretary, Elizabeth Truss, has also ordered more prison staff to be trained as part of the specialist Tornado anti-riot squads after eight serious disturbances and riots broke out in the prison system in the last three months.

The latest quarterly “safety in custody” statistics are expected to confirm the increasingly volatile state of prisons in England and Wales. Self-inflicted deaths are expected to have risen to 113 in 2016, while incidents of self-harm have increased by more than 25%.

If confirmed, the final figure of 113 self-inflicted deaths in 2016 will compare with 89 in 2015 and the previous record high of 96 in 2004.

One key indicator of prison violence – assaults on staff and other inmates – is thought to have risen by more than 33% to an average of 65 a day across the prison system.

Official figures obtained by the Guardian under the Freedom of Information Act reveal that the number of incidents requiring the specialist Tornado riot squads to regain control of a prison tripled between 2013 and 2015.

The riot squads, which are specially trained to handle violent disorder, were called out five times in 2013, 16 times in 2014 and 15 times in 2015. The Ministry of Justice has not yet released figures for the Tornado squads for 2016, but recent figures for the deployment of the national tactical response group which deals with more minor incidents including rooftop protests, showed they were being deployed more than 60 times a month last summer.

Truss has told MPs that the existing force of 2,000 Tornado-trained prison staff is being increased “to make sure we can deal with any incidents that arise across our prison estate, particularly while we are building up the strength of our frontline”. An extra 2,500 prison staff are being recruited partially to reverse the deep cuts which have seen 8,000 fewer staff working in prisons over the past six years.

The justice ministry has also launched an internal inquiry following the recent inquest into the death of Dean Saunders, a prisoner at Chelmsford jail, who had mental health problems when he was sent to prison.

Dr Phillip Lee, a junior justice minister, has begun an inquiry into recent deaths in custody to see whether there is a pattern in why they are happening and whether policy changes are needed to the way mental health assessments are conducted in prisons.

Deborah Coles, director of Inquest,said: “This is a complacent response. Dean should never have been in prison in the first place. His death was entirely preventable.

“There have been repeated failures to act on the repeated recommendations arising from investigations, reviews, inspection and monitoring boards. We don’t need more reviews – the evidence is all there. It just needs government to take decisive action.”

Her reaction was supported by the shadow justice secretary, Richard Burgon, who said during a Commons debate that evidence from monitoring boards and inquest juries suggested too many people with mental health problems were in prison. “What needs to happen is that the ministry must ensure the recommendations of such bodies are acted upon,” he said.

Truss told MPs that immediate action was being taken to improve security and stability across the prison system, including the recruitment of 2,500 extra prison officers. She is shortly to introduce a new prison and courts reform bill to transform prisons, reduce reoffending and get prisoners into employment.

MoJ launches inquiry after record number of prison suicides in 2016

Sharp rise in number of patients turned away from A&E

The number of patients being turned away from A&E and sent to other hospitals is at a record high, figures show, revealing the huge pressure the NHS faces this winter.

More patients arriving by ambulance were redirected to other hospitals this year compared with the same period over the last four years. Such incidents are referred to as diverts. The NHS has previously said that diverts caused by lack of physical or staff capacity should be a last resort.

Guardian analysis of NHS England data showed that from 2 to 23 December the number of patients forced to go elsewhere increased by 73% to 95 compared with the previous year, when the number was 55. There were 60 incidences in 2014 and 16 in 2013 – 2012 figures could not be included because of how they were recorded.

The rising trend has prompted concern that patients’ health could suffer as a result of the delay to them receiving medical attention due to diverts.

The chief executive of the Patients’ Association, Katherine Murphy, said ambulance diversions meant it took longer for patients to get care. “When someone needs access to care they need it. Diverting isn’t an answer to providing a safe system,” she said.

Murphy added that there was huge pressure on hospitals now all year around, not just in the winter period. She put this down to the fact that patients often stayed in hospital longer than necessary because of inadequate social service provision. This meant those who needed an acute bed often had to go to another hospital.

An NHS England spokesperson said: “Common sense means that ambulances spread the emergency load between neighbouring hospitals, including a very small number of diverts – 19 [in the week before Christmas] compared with an average of 20 a week over the past year. While hospitals are under pressure they have generally been coping with the increased number and severity of winter illnesses.”

While the NHS says that there were only 19 in the week leading up to Christmas, there were 36 diverts from 12 to 18 December, with the weekly average up on last year.

Dr Mark Porter, the British Medical Association chair of council, said: “Every one of these diverts is a patient unable to get the treatment they need from an overstretched NHS, deprived of resources and failing to keep up with rising demand. Frontline staff are under serious pressure and are working flat out, but the system can’t cope with the number of patients needing to move through acute care, as it is congested.

“We can only get to grips with pressure on A&E if every part of the system – from general practice to social care – is adequately funded, supported and working well.”

In October the performance of hospitals against the crucial target of 95% of A&E patients being treated and either admitted, discharged or transferred within four hours was the fourth worst since records began.

The NHS is on track to have its most difficult winter ever. A total of 785,883 patients – up from 613,971 last year – could end up waiting more than the supposed maximum four hours for A&E care in the December to February months. This is based on a 28% year-on-year rise in such delays seen each year between 2010-11 and 2015-16, according to Incisive Health, a specialist health communications and policy firm.

Meanwhile, the number of cases of norovirus is at a five-year high. Data from Public Health England shows the bug had reached 2,435 this season, 12% more than the average for the same period over the last five years.

The shadow health secretary, Jonathan Ashworth, said A&Es up and down the country were under pressure. “Not only do we now know the scale of diverts, we also know that over recent months hundreds of thousands of patients have been forced to wait longer than four hours in A&Es. As well as this, more and more patients are increasingly waiting on trolleys.”

Sharp rise in number of patients turned away from A&E

This May Be The Number ONE Food to Prevent Stroke, High Cholesterol, and Blood Pressure

This May Be The Number ONE Food to Prevent Stroke, High Cholesterol, and Blood Pressure

LDL Particle Number: Possibly an Accurate Predictor of Heart Disease Risk

Many people today prefer to consume foods that contain less cholesterol such as lean meat, eating eggs by discarding the yolk or only taking a few eggs per week, and avoid eating seafood as they are believed to have high cholesterol levels. The main reason behind that is because we have been told that dietary cholesterol in foods raises blood cholesterol.

More recent evidence does not support the idea, which is based on a study performed on rabbits 50 years ago.

What is cholesterol?

Cholesterol is an organic molecule, a fat-like substance that occurs naturally in our body and all other animals living on earth. It is a 27-carbon molecule that many scientists and general public view it as being harmful, to the contrary, it is essential for our body to function.

Being a steroid alcohol, it can be “free” or “esterified” which is its active form. It also can exist in its “esterified”, a storage form which is known a cholesterol ester.

Cholesterol contributes to the strength of the membrane structure of every single cell in our body. It plays a crucial role in strengthening lipid rafts that contain protein-based molecules such as receptors and ion channels.

It is a building block for the production of vitamin D and various steroid hormones (including reproductive hormones) and bile acids. It is a very little known fact that cholesterol and its derivatives, namely vitamin D, bile acids, and bilirubin act as antioxidants.

Dietary cholesterol has little effect on body cholesterol

All this while, many people believe that dietary cholesterol would raise blood cholesterol levels. It’s only true for some people that are ‘high responders, which comprises about 25% of the population.

It’s also so true for diabetics, for instance, they are advised against taking eggs as elevated free radicals caused by high blood glucose (oxidative stress) leads to oxidative damage – meaning damage occurs at cellular levels to plasma and mitochondrial membrane. This condition causes blood cholesterol levels to rise because they are needed to repair both membranes.

Our body tightly regulates the synthesis of cholesterol by producing almost all the cholesterol it needs. At the same time, it absorbs a relatively small amount of cholesterol from foods containing it. When our dietary intake of cholesterol decreases our body would respond by producing more cholesterol. In contrast, when we eat larger amounts of cholesterol, our body produces less.

Most of the dietary cholesterol is not absorbed and is excreted by our gut in the form of stool. Much (> 50%) of the cholesterol we ingest from food is esterified, hence we don’t actually absorb much if any, exogenous cholesterol (i.e., dietary cholesterol). As only unesterified cholesterol is easily absorbable, dietary cholesterol which is high in esterified cholesterol has to be de-esterified to become an unesterified form in order to be easily absorbed into hepatic veins.

The aforementioned arguments are typically ignored by many scientists, dieticians, allopathic doctors, and educators. Their ignorance is believed to stem from focusing too much on lectures and materials in their college-year textbooks. The truth is that the material they obtain from lectures and textbooks can be very out of date.

Dr. Peter Attia says,

“About 25% of our daily “intake” of cholesterol – roughly 300 to 500 mg — comes from what we eat (called exogenous cholesterol), and the remaining 75% of our “intake” of cholesterol — roughly 800 to 1,200 mg – is made by our body (called endogenous production).  To put these amounts in context, consider that total body stores of cholesterol are about 30 to 40 gm (i.e., 30,000 to 40,000 mg) and most of this resides within our cell membranes.”

Our liver synthesizes about 20% of the made or synthesized cholesterol while the rest (80%) is synthesized by other cells in our body. This may be translated as only very few cells require a delivery of cholesterol because most of the cholesterol resides within our cell membranes.

Does particle size matter?

Low-density lipoprotein (LDL) is responsible for carrying cholesterol particles throughout our body. It makes up 60–70% of total blood lipoproteins and often referred to as “bad” cholesterol because it has been linked to atherosclerosis, or the buildup of plaque in arteries. High LDL levels are associated with an increased risk of heart disease – the higher the level, the greater the risk.

There are different types of LDL categorized according to particle size, namely small LDL, dense LDL or large LDL. People who have mostly small LDL particles are found to be at a greater risk of developing heart disease than those with mostly large LDL particles.

Still, some scientists argue that the most important risk factor is not the size of LDL particles. It is the number that matters the most. This measurement is called LDL particle number, or LDL-P. In fact, the higher number of LDL particles one have, the greater his/her risk of developing heart disease. Some experts believe it is a much more accurate of cardiovascular disease risk than either LDL or total cholesterol levels.

Elevated LDL particle number – affected by triglycerides levels

Besides cholesterol, LDL also carry triglycerides, fat-soluble vitamins, and antioxidants. You may imagine LDL primary task is to deliver all those vital nutrients to cells and tissues of the body.

Each LDL has a certain limit in term of the number of cholesterol it can carry. When the number of triglycerides increases, the amount of cholesterol it carries decreases, which in turn causes the liver to produce more LDL particles to transport the same amount of cholesterol around the body.

Elevated LDL particle number – mechanism

Several factors have been associated with elevated LDL-P, including insulin resistance, metabolic syndrome, poor thyroid function, infections, leaky gut, and genetic. Mechanism of each factor is not discussed here as it would make the article becomes very long.

In alternative medicine, well-trained practitioners would always focus on finding the underlying or root cause of the problem. After identifying, appropriate measures such as lifestyle changes are always used as the first line of treatment. In a case of leaky gut, for instance, clients are always advised to change their diet by avoiding foods believed to exacerbate the condition while at the same time take more foods thought to be beneficial in alleviating it.

If the clients experience chronic stress, they are advised to manage the stress diligently. Some herbs such as adaptogens and relaxants may also help to relieve the stress. Most of the time, proper lifestyle intervention makes medication unnecessary.

All the factors associated with elevated LDL-P are believed can be addressed by adopting proper lifestyle changes, except genetic.

Note

Heart disease is a complex, multifactorial process, therefore, the likelihood of having a heart attack depends on numerous factors. This article does not suggest that LDL-P is the only risk factor that matters, or that other risk factors should not be taken into consideration.

Oxidized cholesterols and other oxidized lipids such as lipid peroxides, polycyclic aromatic hydrocarbons (PAHs) and aldehydes, all of which formed when vegetable oils are heated and carried by LDL are also believed to be possible causes of atherosclerosis. So, frequent consumption of deep fried foods especially fried using polyunsaturated fats might not be a good idea. Chronis stress, smoking, heavy drinking, and toxin overload due to poor diet, overeating, or poor detoxification are also believed to cause atherosclerosis.

Studies also found that polyunsaturated fats are easily oxidized to aldehydes even when heated below smoke point. Aldehydes are potent oxidizing agents, meaning they are able to oxidize any molecules including that in the cell membrane, ie., various ion channels (for instance, they cause damage to calcium channel, eventually may cause calcium to enter cells at higher levels, which results in atherosclerosis).

LDL Particle Number: Possibly an Accurate Predictor of Heart Disease Risk

Sludge Potion Number Nine

On your next trip to Home Depot or Lowes make sure to stop by the garden section and find a bag of Milorganite 5-2-0 Fertilizer. The bag with a picture of  bright green turf, a nice home, a little boy and a fluffy dog playing ball, with the sun shining and the blue sky. Big letters will inform you – “Organic Nitrogen Lawn Fertilizer. For better results. Naturally. Eco Friendly”.

Ahhh, the joy of a natural, wholesome way of living….

THE FINE PRINT

I confess – I have a nasty habit of reading the small print, always trying to find some high fructose corn syrup in a can of “homemade” lemonade, or soybean meal in a bag of “all natural” dog food. And so here I am, doing it again. Safety Data Sheet (SDS) of Milorganite provides a wealth of information, if you care to comb through the 8 pages of it. ¹

Product description – A fertilizer product manufactured from various microbes used to digest sewage sludge.  Supplier – Milwaukee Metropolitan Sewerage District.

Let’s see if I can translate this; this bag is full of microbes that eat sewage. Milwaukee sewage to be precise. Or maybe it’s a bag of Milwaukee sewage sludge with some microbes in it? Either way – that doesn’t sound very organic.

This product is classified and labeled according to the Globally Harmonized System (GHS).² Below – an exclamation mark inside a red square and a mysterious GHS07 code. According to the GHS means: “substances and mixtures irritating to the skin, eyes and respiratory tract”.

Hmmm. Shouldn’t that little boy on the picture wear protective gloves and eye/face protection?! That’s what the SDS advises on the bottom of the page 1 under Precautionary Statements.

And what about the fluffy dog?

On page 3 under the caption – Handling and Storage, I read with sinking heart:

“Some coprophagic canines may be attracted to the odor of biosolids, transfer their fecal attraction to Milorganite Fertilizer, rip open bags and over eat. A dog may be sick for 24-48 hours”.

“Vomiting that can lead to dehydration, incontinence (stiffness in hind legs), atrophy, depression…”

OK, now they really got my attention! I’m a dog person; I don’t want this sweet canine to suffer from atrophy and depression!

But let’s not stop here, my reading continues.

On page 2; Dangerous components. Activated sewage sludge, microbes. Skin irritant, eye irritant. Aquatic acute – code H401. I make a beeline back to the Globally Harmonized System; H401 stands for – Toxic to Aquatic Life.

Maybe that nice house has a goldfish pond in the back? Will the goldfish die? Somebody should tell the parents of that boy before he finds his goldfish floating belly up!

Special hazards arising from the substance or mixture: At high temperatures, this type of fertilizer can give off undefined fumes.

It is definitely sunny in the picture, so it’s possible that it’s hot.

Maybe I’m overreacting. Page 5 provides a momentary reassurance: Chemical stability: Stable under normal conditions.

On  second thought,  what are “normal conditions”?

Where was this picture taken? Maybe this is a suburb of Houston on an August afternoon? Likely the temperature will be around 100F and humidity at least 80%. Is that “normal”?

But let’s move along, bottom of this same page 5:

Biosolids have the potential to contain various pollutants. (…) The U.S. Environmental Protection Agency has extensively analyzed the risk from these pollutants. These analyses have considered over 400 compounds.

RISK EVALUATION – EPA STYLE

Let’s take a closer look at the EPA evaluation of those 400 compounds. EPA indeed in 2006-2007 conducted the Targeted National Sewage Sludge Survey (TNSSS), collecting 84 samples from 74 publicly owned treatment works (POTW).¹⁴ They analyzed collected sewage sludge samples for 145 analytes.  The analysis included anions, metals, polycyclic aromatic hydrocarbons, semi-volatiles, flame retardants, pharmaceuticals, steroids and hormones. The findings were published in 2009; anions, 27 metals, three steroids and flame retardants were found in every sample and semi-volatiles and aromatic hydrocarbons found in at least 72 samples.

What EPA usually does for “extensively assessing the risk” is a method called – Qualitative Risk Assessment (QRA).¹⁵ The method employs complex mathematical formulas to measure whether the practice, product or structure is reasonably safe. The QRA approach works fine when designing a bridge; you figure out how many rivets are needed on a particular section of a bridge that experiences heavy traffic during rush hours, using that amount will prevent the bridge from collapsing. When assessing a health risk from the exposure to a toxin, the method is an unfortunate choice.

For example; EPA can live with soil containing 300 ppm of lead.  They only consider a 150 lb male, ignore the unborn, elderly, ill; ignore other sources of lead exposure, and viola, if soil contains 300 ppm of lead–especially when averaged– in playgrounds and farms, it is safe.  In reality, NO amount of lead in soil is safe.¹¹

The TNSSS reports warns – “It is not appropriate to speculate on the significance of the results until proper evaluation has been completed”.

OK, I will not speculate then.  But – wait! The report was issued in 2009, now we have the end of 2016. Seven years later maybe is an appropriate time to not so much speculate but perhaps – reach some conclusions on the significance of those findings?

The 503 rule¹⁶ – federal regulatory document remained unchanged since its implementation in 1993.  It calls for testing of nine heavy metals, two indicator bacteria, phosphorus and nitrogen. That’s it. Not “145 analytes” or “400 compounds”. Biosolids Class A, that’s what Milorganite is, if tested at all – is tested only in accordance with the 503 rule – nine heavy metals and two bacterial indicators.

I continue with the Safety Data Sheet, page 5 informs us that:

In biosolids, pathogens may present risk. (…) To destroy pathogens, Milorganite is heated to 176F and dried.

 

 INDEPENDENT RESEARCH FINDINGS

I breathe a sigh of relief, I should be able to reach an educated conclusion on this piece of information. By pure coincident, I recently happened to read a very interesting research article from Canada. ¹³

Researchers in this study collected several sewage sludge samples from two different biosolids treatment facilities over a period of one year. One plant treats waste activated sludge by anaerobic digestion and dewatering process. A second plant participating in the study treats sludge by a dewatering/pelletization process, combined with thermal drying. Several cutting-edge molecular techniques were used to assess the pathogen content of samples collected. The study concluded that the technology used by the second plant was more effective in killing off the bacterial load in sludge. Two indicator bacterial species that are federally regulated were indeed undetected in the treated sludges. The problem is – other bacteria were detected, species that are not required to be monitored. An opportunistic pathogen, such as Clostridium spp., produces endospores that are heat resistant and survive both modes of treatment. Clostridium is a causative agent for botulism, tetanus and enterocolitis.

If indeed the Milorganite is heated to 176F, what do you think happens to the heat-resistant Clostridium endospores? That’s right – nothing.

Another published study done by the Yale University scientists concludes that all samples of municipal wastewater residuals they collected contained pathogens.³ In this study researchers found DNA fingerprints of opportunistic pathogens in all collected samples, 61% of those pathogens were of the genera Clostridium and Mycobacterium.

It just happens that Mycobacterium tuberculosis, a causative agent of pneumonia is heat resistant.⁴ If heating those bugs to 176F doesn’t kill experimental colonies on a petri dish, do you think it will kill them at the wastewater treatment plant? Maybe that sheds some light on why so many residents exposed to the dust from biosolids amended soils suffer from respiratory conditions.

ORGANIC FERTILIZER OR A CAN OF WORMS?

It’s impossible to truly assess the pollutant and pathogen content of a bag of Milorganite. Or any other sludge-derived “natural fertilizer”. The methods of monitoring implemented by the EPA are grotesquely inadequate, if anything, they do more harm than good. To a poorly informed public they give an illusion of protection, of an orderly and well-organized practice compliant with the main mission of the EPA – to protect the natural environment.

Treated sewage sludge, be it Class A (Milorganite, etc.) or Class B (agricultural biosolids), is mostly an unknown and unknowable mixture of toxins, pollutants, pathogens and just about any naturally occurring and man-made harmful substance. It’s concentrated million folds during the dewatering process and only partially deactivated. Not only do we have a very poor understanding of what exactly are the harmful components of sludge, but we know even less about all of  the possible interactions that take place when all the components of sludge are treated/heated and then spread on the land. The permutations of possible interactions are practically endless. ⁸

If you pick up a bag of Cheetos and look at the list of ingredients; you know you will be eating a highly processed corn product with artificial coloring and preservatives. You can make an informed decision to eat it or toss the bag.

Nobody truly knows what toxins and in what quantities hide in a bag of biosolids; what bacterial and viral pathogens mixed with a myriad of other toxins are spread in the parks and gardens across the country. ^5,6 Polycyclic aromatic hydrocarbons; semi-volatile organics; inorganic anions; polybrominated diphenyl ethers (PBDEs); antibiotics and their degradation products, disinfectants and other antimicrobials, steroids, hormones, the list goes on and on and on…..^7,9,10,12

What is needed to assess risks from the biosolids exposure is exposure studies. Most importantly – we need to stop the practice of spreading pollutants and toxins on the land.

References:

1. 36lb/16kg bag Milorganite 5-2-0. Safety Data Sheet (SDS) OSHA HazCom Standard 29 CFR 1910.1200(g) and GHS Rev 03. http://www.milorganite.com/-/media/Milorganite/Documents/MSDS/520_SDS_2015.pdf


2. A Guide to The Globally Harmonized System of Classification and Labeling of Chemicals (GHS). https://www.osha.gov/dsg/hazcom/ghsguideoct05.pdf


3. Bibby K, Viau E, Peccia J. Pyrosequencing of the 16S rRNA gene to reveal bacterial pathogen diversity in biosolids. Water Res. 2010 Jul;44(14):4252-60.


4. Doig C, Seagar AL, Watt B, Forbes KJ. The efficacy of the heat killing ofMycobacterium tuberculosis. Journal of Clinical Pathology. 2002;55(10):778-779. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769777/


5. Harrison, E.Z., McBride, M.B. and Bouldin, D.R. (1999) ‘Land application of sewage sludges: an appraisal of the US regulations’, Int. J. Environment and Pollution, Vol. 11, No. 1, pp.1–36. http://cwmi.css.cornell.edu/PDFS/LandApp.pdf


6. Jones C.C. 2011. Environmental Justice in Rural Context: Land Application of Biosolids in Central Virginia. Environmental Justice, vol 4, no 1, pp 1-15. http://online.liebertpub.com/doi/abs/10.1089/env.2009.0034


7. Kim, S. et al. 2007. Potential ecological and human health impacts of antibiotics and antibiotic-resistant bacteria from wastewater treatment plants. Journal of Toxicology and Environmental Health Part B–Critical Reviews 10: 559-573.


8. Lewis, D. L. et al. 2002. Interactions of pathogens and irritant chemicals in land applied sewage sludges (biosolids). BMC 2: 11. http://www.biomedcentral.com/1471- 2458/2/11 43.


9. Lewis D.L. (1998) Microbes in the environment: challenges to exposure assessment. Science and the Unpleasant: Risk Assessment and Urban Sewage Sludge. Panel Presentation at the American Association for the Advancement of Science


10. Peccia J. 2016. A Guide to Sewage Sludge Exposure during Land Application.


11. Snyder, C. 2008. Baltimore sludge pilot project puts children at additional risk. Int. J. Occup. Environ. Health14(3): 241


12. Snyder, C. 2005. The Dirty Work of Promoting the “Recycling” of American Sewage Sludge. Int. J. Occup. Environ. Health 11: 415-427. http://www.sludgefacts.org/ IJOEH_1104_Snyder.pdf


13. Yergeau, E. et al. 2016.Comparison of Methods to Identify Pathogens and Associated Virulence Functional Genes in Biosolids from Two Different Wastewater Treatment Facilities in Canada. Plos One 11(4): e0153554. https://www.ncbi.nlm.nih.gov/pubmed/27089040.


14. Targeted National Sewage Sludge Survey. Sampling and Analysis Technical Report. United States Environmental Protection Agency. January 2009. https://www.epa.gov/sites/production/files/2015-04/documents/targeted_national_sewage_sluldge_survey_sampling_and_analysis_technical_report_0.pdf


15. Sustainable Futures / P2 Framework Manual 2012 EPA-748-B12-001 13. Quantitative Risk Assessment Calculations. https://www.epa.gov/sites/production/files/2015-05/documents/13.pdf


16. A Plain English Guide to the EPA Part 503 Biosolids Rule. EPA/832/R-93/003 September 1994

Sludge Potion Number Nine

Number of mental health nurses in NHS drops a sixth under Tories

The number of mental health nurses working in the NHS has dropped by almost a sixth since the Conservatives came to power in 2010, new figures show.

The revelation has sparked fresh doubt that government pledges to improve mental health services are being matched by progress at the NHS frontline.

Philip Dunne, the health minister, has admitted in a written parliamentary answer that while there were 45,384 mental health nurses working in England in 2010, there were just 38,774 in July this year. That fall of 6,610 nurses represents the loss of about 1,000 such specialists a year, or almost 15% of the entire workforce providing that sort of vital care to patients over the last six and a half years.

“This is a very worrying downward trend that shows no sign of turning around, despite all the government’s pronouncements and pledges about equality for mental health care compared to physical health care,” said Labour MP Luciana Berger, the ex-shadow health minister who obtained the answer.

The loss of so many posts meant that patients are at risk of receiving lesser-quality care than before and their recovery is being jeopardised by having less contact time with nurses, who were likely to be busier than ever, Berger warned.

The Royal College of Nursing claimed the figures proved that patients were being let down and ministerial pledges of recent years were not being delivered.

“These numbers make it very clear why so many mental health patients are simply not getting the care they need,” said Janet Davies, the RCN’s chief executive and general secretary. “The government has committed to equal treatment of mental and physical illness, but these figures show how far the health system still is from achieving that. Without the right number of nurses, people cannot get the care and treatment they need.”

The ongoing reduction in nurse numbers is also counterproductive because it leads to greater pressure on other public services, Davies added. “Early intervention is the most effective way to tackle mental health problems, but at the moment patients often aren’t being treated until they reach breaking point and problems are escalating out of control. The pressures on mental health services are spilling out into social care, A&E and even police custody.”

Mental health hospitals have seen the biggest fall in nursing staff. A total of 24,581 nurses worked in such settings in 2010 but by July that had dropped to 19,170 – a loss of 5,411 posts (22%).

The number of specialist nurses working with patients with learning disabilities had also fallen by 538 from 2,508 to 1,970, while those in “other learning disabilities” has fallen 44% from 2,628 to 1,483.

The sharp decline shows the coalition government’s pledge in 2014 to bring about “parity of esteem” in NHS treatment of patients with mental and physical health conditions will not be honoured any time soon, Berger added. Urgent action was needed to stem the dwindling numbers before patient care deteriorated further and remaining staff had to cope with even bigger caseloads, she said.

NHS trusts are allowing the number of mental health nurses to shrink because they do not have enough money to employ as many as they need to provide proper care, Berger claimed. Recent freedom of information requests the Liverpool Wavertree MP undertook found that 57% of GP-led clinical commissioning groups, which hold NHS budgets locally in England, planned to cut their spending on mental health this year, despite ministerial pledges that CCGs should increase spending on such services by the same amount as their overall budget rises.

The only area of mental health care to have more nurses working in it than in 2010 is community psychiatry. Some 16,152 such nurses work there now, compared to 15,666 in 2010.

The overall fall in mental health nurses in recent years is even larger – 7,381 rather than 6,610 – if 2009-10, Labour’s last year in power, rather than 2010 is used as the starting point.

The Department of Health said the figures did not give the full picture of the mental health workforce and that the number of both junior doctors and consultants working in psychiatry has been going up.

“Since 2012, the number of trainee doctors working in mental health settings during their foundation programme has more than doubled, we have seen the highest-ever fill rate for core psychiatry training, and mental health nursing trainee places are growing at a faster rate than any other nursing specialty in the NHS.

“This government is determined to address for the first time some of the very deep inequalities that people with mental ill health face, and while we have more to do, progress is being made,” a spokesman said.

Number of mental health nurses in NHS drops a sixth under Tories

Number of vasectomies in England falls 64% in 10 years

Vasectomies appear to have gone dramatically out of fashion, with a decline of 64% in the number of men undergoing the procedure within the last 10 years, leaving women once more shouldering the responsibility for contraception.

But the reasons for the apparent shift are complex, say experts. Part of it is bad publicity, with many men seemingly put off by scare stories about pain and unfounded worries about the implications for their sex lives, but there are also concerns that NHS funding for the procedure may be slipping away.

In 2004-5, there were 31,216 vasectomies carried out in England, but in 2014-15, that fell to just 11,113 according to NHS Digital. Image is definitely an issue, according to Genevieve Edwards of Marie Stopes, who says “the snip” is an offputting misnomer. “That is not what happens. If you were going to launch vasectomy as a product, you wouldn’t start there,” she said.

“People worry massively and have lots of misconceptions about it – how painful it is, the impact on their sex life, whether they will still have orgasms. People are really confused about it.”

The perceptions lag behind the reality, Edwards said. “There is no snipping at all. It is a 15-minute procedure with lots of anaesthetic and Bob’s your uncle.”

But the later age of having children is also a factor, she believes. In the past, a couple may have had several children before they were 30. “If you and your partner had another 20 years of fertility ahead, another two decades of the pill, you might pack him off to the doctor,” she said. But if a woman will be facing the menopause in just a couple of years, they might carry on with contraception rather than opting for a vasectomy.

Suggestions that men no longer want a vasectomy in case their marriage breaks up and they have a second partner who wants children are wide of the mark, she believes.

Marie Stopes is a leading provider of vasectomies for the NHS as well as privately and has been trying to boost interest among men. It ran a campaign this spring on websites and at football grounds called “Have you got the balls?” inviting men to think about it. It appeared to have some effect, because 200 more men came along for the procedure last month than in September the year before.

If awareness and interest is dropping in England, that is not the case elsewhere. Marie Stopes clinics get quite a lot of male clients from France and the Middle East. In the Middle East, the procedure is rarely done, so men head for clinics where it is routine and they feel in safe hands. In France, vasectomy was illegal until relatively recently, under the Napoleonic code that banned self-harm. Although it is legal now, it is not easy to access and men who ask for it must go through counselling and a cooling-off period. Many jump on the Eurostar instead.

But cost in England may be becoming an issue. At a time of increasing financial pressure on the NHS, some clinical commissioning groups are considering reducing the number of vasectomies they will pay for, or dropping them altogether. The North East Essex clinical commissioning group (CCG) will no longer fund it. Its website states: “The community vasectomy and female sterilisation services are considered as one of many forms of contraception and are deemed to have no or limited clinical value.” It will be available, however, “in cases of complex health needs”.

The procedure costs £400, but arguably saves money on other forms of contraception over the long term. It also allows men to take over responsibility from women, who have had to worry about their fertility and the possible side-effects of hormonal contraception for much of their lives.

While vasectomy has declined, the use by women of long-acting reversible contraceptives, known as LARCs – such as implants and intra-uterine devices (the coil) – has risen.

“There has been a huge push on getting women to use long-acting reversible methods,” said Katherine O’Brien, a spokesperson for BPAS, the British pregnancy advisory service. “It is cheaper for doctors to be providing these things. We know that if you speak to women and their partners, if they have discussed the possibility of a vasectomy with their GP, the doctor often says to them, why don’t you just have the coil or an implant?”

The attraction of LARCs is that they can be left for several years but the contraceptive effect is reversible – and a vasectomy often is not. But implants are hormonal, which some women do not want, and sometimes there is bleeding. “When women go back to the GP, they are told to go back on the pill to cope with the bleeding,” said O’Brien. “It is really extraordinary. They chose the LARC because they didn’t want to take the pill.”

The Family Planning Association says it advocates “as much choice as possible”. It too is worried about the decline of the vasectomy and fears there will be a postcode lottery as some CCGs decide to pay for it, while others will not. “We are worried that if men aren’t able to access vasectomy, it does put more of a burden onto women,” said a spokesperson. The conversation heard in the clinic is of the woman in a partnership saying that contraception was her responsibility until the couple had completed their family – and now it is the man’s turn.

The vasectomy is a simple procedure, carried out under local anaesthetic. It involves a small incision on each side of the scrotum, allowing the doctor to access the tubes that carry sperm out of the testicles. These are cut and sealed. It can also be done with keyhole surgery. Ejaculation is as normal afterwards, but the semen contains no sperm.

Number of vasectomies in England falls 64% in 10 years

Number of vasectomies in England falls 64% in 10 years

Vasectomies appear to have gone dramatically out of fashion, with a decline of 64% in the number of men undergoing the procedure within the last 10 years, leaving women once more shouldering the responsibility for contraception.

But the reasons for the apparent shift are complex, say experts. Part of it is bad publicity, with many men seemingly put off by scare stories about pain and unfounded worries about the implications for their sex lives, but there are also concerns that NHS funding for the procedure may be slipping away.

In 2004-5, there were 31,216 vasectomies carried out in England, but in 2014-15, that fell to just 11,113 according to NHS Digital. Image is definitely an issue, according to Genevieve Edwards of Marie Stopes, who says “the snip” is an offputting misnomer. “That is not what happens. If you were going to launch vasectomy as a product, you wouldn’t start there,” she said.

“People worry massively and have lots of misconceptions about it – how painful it is, the impact on their sex life, whether they will still have orgasms. People are really confused about it.”

The perceptions lag behind the reality, Edwards said. “There is no snipping at all. It is a 15-minute procedure with lots of anaesthetic and Bob’s your uncle.”

But the later age of having children is also a factor, she believes. In the past, a couple may have had several children before they were 30. “If you and your partner had another 20 years of fertility ahead, another two decades of the pill, you might pack him off to the doctor,” she said. But if a woman will be facing the menopause in just a couple of years, they might carry on with contraception rather than opting for a vasectomy.

Suggestions that men no longer want a vasectomy in case their marriage breaks up and they have a second partner who wants children are wide of the mark, she believes.

Marie Stopes is a leading provider of vasectomies for the NHS as well as privately and has been trying to boost interest among men. It ran a campaign this spring on websites and at football grounds called “Have you got the balls?” inviting men to think about it. It appeared to have some effect, because 200 more men came along for the procedure last month than in September the year before.

If awareness and interest is dropping in England, that is not the case elsewhere. Marie Stopes clinics get quite a lot of male clients from France and the Middle East. In the Middle East, the procedure is rarely done, so men head for clinics where it is routine and they feel in safe hands. In France, vasectomy was illegal until relatively recently, under the Napoleonic code that banned self-harm. Although it is legal now, it is not easy to access and men who ask for it must go through counselling and a cooling-off period. Many jump on the Eurostar instead.

But cost in England may be becoming an issue. At a time of increasing financial pressure on the NHS, some clinical commissioning groups are considering reducing the number of vasectomies they will pay for, or dropping them altogether. The North East Essex clinical commissioning group (CCG) will no longer fund it. Its website states: “The community vasectomy and female sterilisation services are considered as one of many forms of contraception and are deemed to have no or limited clinical value.” It will be available, however, “in cases of complex health needs”.

The procedure costs £400, but arguably saves money on other forms of contraception over the long term. It also allows men to take over responsibility from women, who have had to worry about their fertility and the possible side-effects of hormonal contraception for much of their lives.

While vasectomy has declined, the use by women of long-acting reversible contraceptives, known as LARCs – such as implants and intra-uterine devices (the coil) – has risen.

“There has been a huge push on getting women to use long-acting reversible methods,” said Katherine O’Brien, a spokesperson for BPAS, the British pregnancy advisory service. “It is cheaper for doctors to be providing these things. We know that if you speak to women and their partners, if they have discussed the possibility of a vasectomy with their GP, the doctor often says to them, why don’t you just have the coil or an implant?”

The attraction of LARCs is that they can be left for several years but the contraceptive effect is reversible – and a vasectomy often is not. But implants are hormonal, which some women do not want, and sometimes there is bleeding. “When women go back to the GP, they are told to go back on the pill to cope with the bleeding,” said O’Brien. “It is really extraordinary. They chose the LARC because they didn’t want to take the pill.”

The Family Planning Association says it advocates “as much choice as possible”. It too is worried about the decline of the vasectomy and fears there will be a postcode lottery as some CCGs decide to pay for it, while others will not. “We are worried that if men aren’t able to access vasectomy, it does put more of a burden onto women,” said a spokesperson. The conversation heard in the clinic is of the woman in a partnership saying that contraception was her responsibility until the couple had completed their family – and now it is the man’s turn.

The vasectomy is a simple procedure, carried out under local anaesthetic. It involves a small incision on each side of the scrotum, allowing the doctor to access the tubes that carry sperm out of the testicles. These are cut and sealed. It can also be done with keyhole surgery. Ejaculation is as normal afterwards, but the semen contains no sperm.

Number of vasectomies in England falls 64% in 10 years

Number of killings by mental health patients falls

The number of killings by patients being treated for mental health problems is falling, probably as a result of improved NHS care, a major new report reveals today.

But the number of suicides has increased across the UK since the financial crash in 2008 – except in Scotland – with middle-aged men the most likely group to take their own life. There are concerns that every year dozens of patients may be killing themselves after they have been wrongly released from hospital because mental health units have too few beds.

Patients with schizophrenia, psychosis or other disorders committed a total of 870 homicides across the UK between 2004 and 2014, which was just over one in ten (11%) of all killings in that time.

But the total number of homicides carried out by patients fell over the 11 years covered by the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness (NCISH). There were 87 such killings in 2004 and 94 the year after, but that had fallen to 67 in 2014 – a decline of 27% over the decade studied by researchers from Manchester University who undertook the inquiry.

“Why that fall? We hope and we think that there have been improvements in clinical care, especially in improving the management of patients’ substance misuse,” said Professor Jenny Shaw, the inquiry’s head of homicide research.

However, their findings raise questions about the NHS’s supervision of patients after they have been released from hospital. Almost two in five patients who killed someone (38%) did so after missing their most recent NHS appointment and so did not receive drugs or talk to a care co-ordinator or psychiatrist, according to in-depth analysis of 662 of the 870 cases.

The report also found that half (52%) of those who committed a homicide had previously been convicted of a violent crime and almost as many (48%) had been in jail. A quarter (24%) had previously been involuntarily detained, or sectioned, under the Mental Health Act and 6% had been in a secure mental health unit.

Killings by schizophrenics have also fallen, from the 53 seen in 2004 to 43 in 2013 and then 36 in 2014. Overall 369 homicides were carried out by people with a history of schizophrenia or other delusional disorder.

However, killings by mental health patients are not falling as fast as the overall drop in homicides. The 27% fall is less than the 37% drop seen in the latter. As a result the proportion of all killings committed by such patients has risen from 9% in 2001 to the 11% seen in recent years.

The NHS needs to undertake “specific clinical measures” to close the gap, researchers led by NCISH director Prof Louis Appleby recommend. It should improve services for those with mental health problems who are also addicted to drugs or alcohol and do more to stay in touch with patients who are likely to stop being in contact, says the report, which was funded by the NHS’s Healthcare Quality Improvement Partnership.

The researchers are warning that around 200 mental health patients kill themselves every year after being put under the care of community-based crisis teams and looked after in their homes, a third after being discharged from hospital in the previous two weeks.

“The report raises questions whether crisis resolution/home treatment was the most suitable setting for their care and raises concerns that crisis teams are increasingly used due to pressure on other acute services, particularly inpatient beds,” the inquiry found.

Appleby added: “Our findings suggest that we are accepting too much risk in the home treatment these teams offer and that the crisis team is now the priority for suicide prevention in mental health.” Overall 28% of all suicides between 2004 and 2014 were of people receiving NHS help for mental ill-health.

Around half of the 1,700 mental health patients a year who take their own lives in the UK had a history of drug or alcohol problems, the inquiry found. In addition, “there is evidence that economic factors are becoming more common as antecedents in patient suicides. Unemployment and homelessness have increased and 13% of patients who died by suicide had experienced serious financial difficulties in the previous three months” it adds.

• In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here
  

Number of killings by mental health patients falls

Number of UK smokers falls to lowest level

The number of UK smokers has fallen to its lowest level, with just one in six adults now lighting up, according to new official figures, which also show a recent collapse in sales of cigarettes.

Just 16.9% of adults in England now smoke, according to the latest data from Public Health England. Its health experts also revealed that widespread use of e-cigarettes, nicotine patches and gum helped 500,000 smokers last year kick the habit – the highest number on record.

The statistics show that, bar two small blips, smoking prevalence has declined continuously and dramatically over the past 50 years by about two-thirds. In 1974, over 50% of men in Britain were smokers; that had fallen to just 19.1% in England in 2015. Similarly, just over 40% of women smoked back then; last year it was only 14.9%.

There are now just 7.2 million adults in England who smoke. They are far outnumbered by 14.6 million ex-smokers. It is the first time that under 17% of the population are smokers and is down from the 19.3% seen as recently as 2012.

Health campaigners said that smoking’s continuing fall in popularity is due to a combination of tough measures, such as price rises and the introduction of plain packaging, and mass media campaigns urging people to quit.

Doctors welcomed the news but pointed out that about 200 people still die prematurely every day in England as a result of heart attacks, strokes and breathing problems caused by smoking.

Prof Kevin Fenton, PHE’s national director of health and wellbeing, hailed the diminishing appeal of smoking as “amazing”. But he warned that, at 7.2 million, the number of people still lighting up regularly remained worryingly high.

“Alongside unhealthy diet, smoking is the biggest cause of preventable early death in England, accounting for over 78,000 deaths a year,” said Fenton. “Quitters will soon see they have reduced blood pressure, easier breathing and better circulation.”

Graphic

PHE hopes that the figures will encourage even more people to stop using cigarettes. They have emerged just before the start of the annual Stoptober, the agency’s “mass quitting challenge”, which kicks off for the fifth time on 1 October.

Dr Mike Knapton, associate medical director at the British Heart Foundation, said: “Quitting smoking is the single best thing you can do for your heart health. By giving up smoking you’ll be dramatically reducing your chances of having a potentially deadly heart attack or stroke.”

The breakdown of smoking rates in England’s nine regions shows a north-south divide. The north-east has the highest proportion of smokers at 18.7%, closely followed by the north-west and Yorkshire and the Humber, in each of which it is 18.6%.

The south-west has the lowest percentage. Just 15.5% of adults there light up. It is 15.7% in the West Midlands, 15.9% in the south-east and 16.3% in London.

Poorer people are also much more likely to smoke than the better-off. While one in five (20.4%) of the most deprived people in England light up, just 14.3% of the least deprived in society do so.

People of Asian backgrounds are the least likely to smoke – just 10% do so. Smoking is commonest among those of mixed race, of whom 22.4% light up.

Smoking’s decline is also underscored by data from consumer analysts Nielsen showing that the number of cigarettes sold in England and Wales has plunged by 20% in the past two years.

PHE said that about 2.5 million people tried to give up smoking last year. Just over a million of them used e-cigarettes to boost their efforts, while about 700,000 were helped by nicotine replacement therapy products, such as gum and patches.

Of those 2.5 million would-be quitters, one in five succeeded – the best-ever rate. That was up from the 13.6% success rate seen as recently as 2010.

Deborah Arnott, chief executive of the campaign group Action on Smoking and Health (Ash), said: “The continuing decline in smoking prevalence is a tribute to many years when successive governments have implemented comprehensive and progressive tobacco control strategies, including tax rises, mass media campaigns, anti-smuggling measures, smoke-free laws, advertising bans, and last but not least getting rid of tobacco displays and glitzy tobacco packaging.”

However, Ash is “very concerned” that government funding for mass media campaigns – which are proven to be effective at prompting people to try to quit – has fallen sharply from almost £25m in 2009-10 to just £4m in 2016-17. Arnott called on ministers to reverse that trend, increase investment in such initiatives and publish a new tobacco control strategy, as the last one expired at the end of 2015.

Rosanna O’Connor, PHE’s director of drugs, alcohol and tobacco, said: “Marketing campaigns and price increases are especially useful in triggering quit attempts.

“But we are also influenced by the people around us. The more ex-smokers there are among your friends and family, the more likely you are to quit for good and the less likely your children are to start.”

Number of UK smokers falls to lowest level

9/11 health crisis: death toll from illness nears number killed on day of attacks

The death toll among those sickened by the toxic dust and ash of Ground Zero will within as little as five years exceed the number of people killed on the day of the 9/11 attacks, experts say.

As those who lost loved ones at the World Trade Center, at the Pentagon and on Flight 93 gather for Sunday’s 15th anniversary of the terror attacks that killed almost 3,000 people, a post-9/11 health crisis is growing.

At least 1,000 people – and probably many more – have died often lingering, painful deaths resulting from illnesses related to their exposure to debris that spread from the wreckage of the World Trade Center towers in downtown Manhattan. More than 37,000 are officially recognised as sick.

Calls are growing for a new monument to be added to the World Trade Center site, to pay tribute to those who have died or become sick since 9/11 because of toxic exposure.

“Within the next five years we will be at the point where more people have died from World Trade Center-related illnesses than died from the immediate impact of the attacks,” said Dr Jim Melius, a doctor at the New York State Laborers Union who also advises the White House on worker health, chairs the steering committee overseeing the government health program for 9/11 responders, and is a member of the advocacy group 9/11 Health Watch.

“There are a lot of people who are very, very ill with lung disease who will see at least 10 years taken from their normal life span,” he said, “and we are already seeing many more premature deaths occurring, and among younger people, from the cancers. There is going to be a new generation of widows and widowers.”

In 2001, government officials, most prominently the then head of the Environmental Protection Agency (EPA), Christine Todd Whitman, assured those in lower Manhattan in the days after the attacks that the air was safe.

In an interview with the Guardian this weekend, Whitman said for the first time that in hindsight she had been mistaken. She apologised to those affected by the toxic debris.

After al-Qaida terrorists flew hijacked passenger jets into the north and south towers of the World Trade Center, the towers collapsed. Clouds of fumes and debris billowed out over New York City. Of 2,977 people killed in the attacks, 2,753 died at the World Trade Center.

The debris left by the twin towers, the main concentration of which became known as “the pile”, contained asbestos, lead, glass, heavy metals, concrete, poisonous gases, oil and other dangerous substances that mixed with exploding jet fuel, the contents of hundreds of offices and dead bodies to fill the air and cover the area around the site.

“It was disgusting,” said Merita Zejnuni, 52, a cleaner who was working a few blocks from Ground Zero in the offices of banking giant Goldman Sachs on the morning of 9/11. “It coated your mouth and your throat. I was covered in it – I looked like a ghost.”

Zejnuni developed a violent, chronic cough and was recently found to have breast cancer. This weekend, speaking to the Guardian, she gave her first interview. Her lawyer, Troy Rosasco, said Zejnuni only found out last month she could apply for compensation. Rosasco believes thousands of other people are sick or dying as a result of exposure around Ground Zero, away from the public eye.

“There is a general consensus that people down there got huge exposure,” he said, “but many don’t even know why they are sick.”

Last month, researchers at Stony Brook University announced that cognitive impairment, a leading risk factor for Alzheimer’s disease, was being detected among first responders who went to Ground Zero on and around 9/11.

“That’s scary news,” said Rosasco. “I have probably gotten 50 calls in the last two days from people who are really frightened about that.”

In 2010, after years of political battle, Congress passed the $ 4bn Zadroga Act – named for a police captain who worked on rescue efforts at Ground Zero and died in 2006 after developing breathing problems – to cover the health costs of those poisoned by the debris and fumes of 9/11. Late last year, it agreed to extend the act’s provisions for 75 years. There is a separate, official Victim Compensation Fund.

In 2011, the federal World Trade Center Health Program (WTCHP) was established. It has 75,000 registered members, 87% of whom worked on rescue, recovery and clean-up. The rest are New York residents or workers. A total of 1,140 registered members have died since the program was created in 2011, WTCHP spokeswoman Christy Spring said.

“Because of the way the legislation was written,” she said, “there is an understanding that there is a link between the exposure and the illnesses people are suffering from.”

Causes of death are not recorded by the WTCHP. There is no central record for how many people died between 2001 and 2011 from illnesses linked to 9/11 fumes and debris, Spring said, nor any way of knowing exactly how many other people have died without any record of their illnesses having been caused by exposure near Ground Zero.

Melius said: “We know a significant number of people died before the WTCHP was set up; it’s likely to be in the hundreds. There are also probably hundreds of people outside the program who are sick and may have died.”

The WTCHP has certified 37,000 people as suffering from serious respiratory or digestive illnesses, cancer, or a combination. Most of those registered are from New York City and 82% are male.

Spring said: “There are health conditions covered in the program that will take years to develop and we don’t think the cancers we are seeing now is the end of it. It’s such an unprecedented disaster. It’s mind-boggling to think not just about the day but about the ripple effect on people’s health.”

The Manhattan borough president, Gale Brewer, told the Guardian she had “heard very high numbers” of people were at risk of dying from exposure to World Trade Center-related toxins.

“Many more than 3,000 or 4,000,” she said. “It’s very sad. I believe it will eclipse the number who died on 9/11 itself, because so many people were on the pile, or came to help, and so many people worked in the area. We are going to be dealing with this for years and years.”

In 2014, Brewer wrote to New York governor Andrew Cuomo and New Jersey governor Chris Christie, asking them to approve a plan to build a monument to those sickened and killed since 9/11, to be installed near where the towers stood.

The area now hosts the National September 11 Memorial and Museum and is dominated by monuments built where each tower stood and engraved with the names of those who died in the atrocity.

Brewer is lobbying for a competition to design a separate monument for those who have been sickened. It will not have names, because of lack of clarity about cause of death in all cases and because it will also be designed to offer solace to those still living but sick, she said.

“It needs to be universal,” she said.

She has had no formal response from either Christie or Cuomo. But when she collared Cuomo at the Democratic convention in Philadelphia this summer, she said, he told her: “Sounds good.”

Brewer is hopeful of adding the monument before the 16th anniversary of 9/11.

Jerrold Nadler, the US congressman whose district includes the World Trade Center site, said of the post-9/11 health crisis: “It’s ghastly, it’s horrible, the people will die early and I feel very frustrated because it was preventable.”

9/11 health crisis: death toll from illness nears number killed on day of attacks