Casebook - July 2019

July 2019 Edition

In this edition of Casebook: back to school asthma, the challenges of obesity in rural areas, the NHS as a climate change leader, pensions and their implications and the ongoing process of ignoring the adult social care “elephant in the room” plus some “other stuff” on action research, mental health first aid, coasts and the Interim People Plan….


Boys more likely to need help for 'back to school asthma'

Very few people like to go back to school and this is a really interesting phenomenon with fascinating social and contexts. This story tells us:

Boys with asthma are twice as likely as girls to visit their GP with worsening symptoms during the first weeks of the new school year, research suggests. 

It found a tripling of appointments related to "back to school" asthma in England.

Being exposed to new viruses at school and a relaxed use of inhalers over the holidays could be factors, experts say.

Asthma could turn into "a ticking time bomb" during the summer holidays, Asthma UK said.

In recent years, there has been a sharp rise in school-age children with asthma being admitted to hospital in September, around the start of the autumn term.

These increases, called the "back to school" effect, were also found in Scotland and Wales.

"Back to school asthma" is thought to account for up to a quarter of serious bouts of asthma in many northern hemisphere countries. 

This Public Health England analysis, based on data from hospitals and GPs surgeries in England from 2012-16, also found evidence of the effect in pre-school children, as well as in five- to 14-year-olds.

Compared with the summer holidays, doctors' appointments related to asthma were two to three times higher in the weeks after school began. And this was particularly marked in boys, according to the research, in the Journal of Epidemiology & Community Health, although it is not clear why.

There were no post-summer peaks in children over 15, when girls were more likely than boys to seek treatment.

The researchers said there could be many reasons for the "back to school" effect.

Dr Alex Elliot, consultant epidemiologist at Public Health England, said: "The reasons underlying 'back to school' asthma are complex, most likely involving seasonal viruses and environmental factors and a greater understanding of these elements will help design future public health approaches."

He also suggested the role of fungal spores could be an area for future research to investigate.

Full details:

Obesity rivals smoking as cause of cancer, UK charity warns

We know that notwithstanding its role as the origin of much of the food we eat and our source of open spaces levels of low exercise and unhealthy eating amongst the young are very high in rural areas. It seems to me that there is no doubt that rural communities will be under significant pressure from obesity in the context of this article.

Obesity is rivalling smoking as a cause of cancer, responsible for more cases of bowel, kidney, ovarian and liver cancer than cigarettes, according to the UK’s leading cancer charity.

Smoking is still the biggest cause of cancer, but Cancer Research UK (CRUK) has warned that government action to tackle obesity is vital, because it is a significant factor in 13 different types of cancer. Obese people now outnumber smokers by two to one.

Michelle Mitchell, the charity’s chief executive, said: “As smoking rates fall and obesity rates rise, we can clearly see the impact on a national health crisis when the government puts policies in place – and when it puts its head in the sand.

“Our children could be a smoke-free generation, but we’ve hit a devastating record high for childhood obesity, and now we need urgent government intervention to end the epidemic. They still have a chance to save lives.”

Full details:

The NHS must behave as an environmental anchor to mitigate the impacts of climate change

This thoughtful article tells us:

The NHS impacts the environment in a multitude of ways. It is responsible for 5% of all road traffic in the UK. Air pollution contributes to an estimated 40,000 deaths each year in the UK and costs the economy an estimated £22 billion — which means that the NHS directly contributes to 2000 deaths from air pollution. The NHS is one of the UK’s most energy intensive organisations, spending more than £750 million on energy each year (including a £350 million greenhouse gas fee) and has the largest carbon footprint of any UK organisation. 

The Sustainable Development Unit has made great advances in raising the profile of the NHS’ carbon footprint, however—its resources are limited, it is focused on top-down policy change, and it cannot be the only angle from which the NHS addresses its environmental responsibilities.

For frustrated clinicians, at an individual and trust level, what can be done as a “bottom up” approach? The Centre for Sustainable Healthcare has many strategies for front line staff to reduce the 22.7 million tonnes of carbon dioxide equivalents (tCO2e) that the NHS emits every year. After all, 80% of this is due to clinical decisions and models of care. Which gives us even greater impetus to demand better procurement and more environmentally friendly clinical pathways.

Examples include psych susnet, green nephrology, sustainable anaesthesia and sustainable respiratory care. For example, metered dose inhalers (MDIs) account for 5% of the total NHS carbon emissions and have estimated carbon footprints of 500g CO2e per dose, compared to 20g in dry powder inhalers (DPIs). Following the Montreal protocol banning the use of CFC gases in 1987, many countries moved directly to dry powder inhalers while in the UK we still prescribe mainly MDIs. By counselling our patients appropriately, we can reduce the carbon footprint of one of the UK’s biggest polluters.

Full details:

NHS operations cancelled as consultants work to rule in pensions standoff

There is a whole section in the Harding Interim People Plan on this issue. We know that rural areas have some of the most acute challenges in relation to recruitment and retention. A change to address the challenge is clearly overdue!

Hospitals are having to cancel operations and cancer scans are going unread for weeks because consultant doctors have suddenly begun working to rule in a standoff over NHS pensions.

Doctors say the dispute is escalating so quickly that it will send NHS services “into meltdown” and is so serious that it poses “an existential threat” to the health service’s survival.

Changes to pension rules in 2016 mean rising numbers of consultants are receiving large bills linked to the value of their pension. Some are having to remortgage their homes to pay.

Waiting times for treatment, already the worst on record, are worsening as hospitals struggle to find senior doctors prepared to work more than their planned shifts, which could lead to them receiving a pension tax bill of as much as £80,000.

NHS bosses fear the total number of patients in England waiting for non-urgent care such as a hip replacement or hernia repair, which already stands at 4.4 million, could soon head towards 5 million.

Full details:

Peers call for extra £8bn to tackle social care scandal

There are specific pressures which impact on those needing adult social care in rural areas which make it harder for people to live in their own homes independently. The ongoing failure of any serious response to what is now the threat rather than the pleasure of growing old in rural England really is lamentable. This article provides some food for thought in that regard. It tells us:

Peers including former Conservative and Labour chancellors have called for an immediate £8bn investment to tackle the “national scandal” that has left over a million vulnerable older people without proper social care support.

The Lords economic affairs committee said this would restore access and quality of social care services in England to pre-austerity levels and relieve unsustainable pressure on unpaid family carers. A further £7bn a year should be spent to extend NHS-style free personal care to all by 2025, to be paid for out of general taxation.

The chair of the cross-party committee, Lord Forsyth, said it was time for government to stop “faffing around” and properly fund a system that was riddled with unfairness and left people enduring real suffering. “Our recommendations will cost money, but social care should be a public spending priority,” he said.

The committee’s report comes amid growing concern at the state of adult social care after a decade of austerity. The outgoing Tory chair of the Local Government Association, Lord Porter, recently warned that vulnerable people would die as a result of the continuing failure to properly fund social care.

Full details:

Other Stuff

Postcards from the seaside – at this time of year we tend to think of the coast as a place of pleasure. It is very clear from discussions with our members that coastal settings provide some of the most challenging environments for the delivery of  health and social care. Problems manifest themselves in terms of: seasonal work flows, the challenge of recruiting and retaining staff, distance from specialists centres of care, a skewed demography towards the elderly – I could go on! One are where we are hoping this debate can be continued in a solutions focused way is the Parliamentary Inquiry on Rural Health and Care. We have decided to hold an additional session on coastal issues and if you have any insights or would like to give evidence please contact us.

You Are Not Alone (Mental Health First Aid Courses) - The YANA Project was set up by a Norfolk Farming Charity in 2008.  As well as promoting mental health awareness to the farming communities in Norfolk, Suffolk and Worcestershire, YANA also provides a confidential helpline and funding for counselling. YANA has participated in three national Public Health England events, cited as an exemplar project; and has produced a National Directory of Rural Support Groups which has been supported by the Worshipful Company of Farmers and The Prince’s Countryside Fund.

YANA also run Mental Health First Aid courses. YANA recently secured a grant of £25,000 from The Princes’ Countryside Fund which will fund six courses over the next 3 years to ensure that within 3 years there will be a ‘YANA Army’ of over 120 Mental Health First Aiders in the many sectors of the farming and allied industries. Courses will take place in Norfolk and Worcestershire in September.  To apply please email website:

Action Research – the National Centre now has three small action research projects in train: a study of the challenges facing dispensing surgeries in rural areas, community pharmacy and first aid and an exploration of the opportunities to increase rural GP recruitment through the CEGPR(CP) route – essentially an alternative registration pathway for people with applied experience from other relevant settings. If you’d like to know more about any or all of these please let me know.

Interim People Plan – We’ve recently been reviewing the Interim People Plan. It’s a more accessible read than many such documents. It also has three references to rural, which is considerably more than many NHS strategies!!! If you have a take on its key themes you would like to share with us namely:

  • Making the NHS the best place to work
  • Improving the leadership culture
  • Tackling the nursing challenge
  • Delivering 21st century care
  • A new operating model for workforce
  • Developing the full People Plan

Please let us have your views


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